What is the recommended management for a 19-week pregnant patient with suspected hepatic cysts and possible esophageal diverticulum?

Management of Hepatic Cysts and Esophageal Findings in Pregnancy

For this 19-week pregnant patient with suspected hepatic cysts, no treatment or follow-up imaging is required if the cysts are asymptomatic, and the possible esophageal diverticulum should only be evaluated with gastroenterology if symptoms develop—endoscopy can be safely performed in the second trimester if clinically necessary. 1, 2

Hepatic Cyst Management During Pregnancy

Asymptomatic Simple Hepatic Cysts

• No follow-up imaging or treatment is recommended for asymptomatic simple hepatic cysts, as these are benign developmental anomalies that typically follow an indolent course. 1, 2
• Simple hepatic cysts do not require bloodwork or tumor markers, as they are benign lesions without malignant potential. 1
• The initial CT findings describing "low attenuations in the liver likely hepatic cysts" suggest simple cysts, which are extremely common (prevalence up to 18% in the general population). 3

If Symptoms Develop

• Ultrasound should be the first diagnostic modality if symptoms such as abdominal pain, discomfort, or mass effect occur during pregnancy. 1, 2
• MRI (without gadolinium in pregnancy) can be used to characterize hepatic cysts with worrisome features if ultrasound is inconclusive. 1
• Treatment is only indicated for symptomatic cysts causing significant discomfort, with success defined by symptom relief rather than cyst size reduction. 1, 2

Pregnancy-Specific Considerations

• The physiologic changes of pregnancy (increased abdominal pressure, hepatic blood flow changes) do not alter the benign natural history of simple hepatic cysts. 1, 2
• If intervention becomes necessary during pregnancy, the safest approach would be conservative management until postpartum, as volume-reducing procedures (aspiration sclerotherapy or fenestration) are elective and can be deferred. 4, 5

Esophageal Findings Management

Approach to Possible Esophageal Diverticulum

• The CT finding of "appearance of the distal esophagus likely positional, esophageal diverticulum cannot be excluded" does not require immediate gastroenterology evaluation unless the patient is symptomatic. 4
• Gastroenterology referral and endoscopy should only be pursued if the patient develops symptoms such as dysphagia, regurgitation, chest pain, or aspiration. 4

Endoscopy Safety in Pregnancy

• If endoscopy becomes clinically necessary, it can be safely performed in the second trimester (where this patient currently is at 19 weeks). 4
• Upper endoscopy during pregnancy is considered safe when clinically indicated, with the patient positioned in left lateral decubitus to avoid aortocaval compression. 4
• Propofol, fentanyl, and midazolam have not been associated with congenital malformations, though meperidine is preferred for moderate sedation with limited midazolam use. 4
• Endoscopy is contraindicated in placental abruption, imminent birth, ruptured membranes, or hypertensive disease of pregnancy. 4

When to Pursue Endoscopy

• Endoscopy should only be performed if the clinical suspicion warrants it—specifically if symptoms suggest significant pathology that would change management during pregnancy. 4
• Routine screening or elective procedures should be deferred until postpartum to minimize maternal and fetal risks. 4
• The CT description suggests this is likely a positional finding rather than true pathology, making immediate endoscopy unnecessary. 4

Clinical Pitfalls to Avoid

• Do not pursue routine follow-up imaging of asymptomatic hepatic cysts during or after pregnancy—this represents unnecessary healthcare utilization and potential anxiety without clinical benefit. 1, 2
• Avoid ordering tumor markers (CEA, CA19-9) for simple hepatic cysts, as they cannot reliably differentiate benign from malignant lesions and are not indicated. 1, 2
• Do not perform endoscopy for the esophageal finding unless symptoms develop—the CT description indicates uncertainty and likely positional artifact. 4
• If endoscopy is performed, ensure proper left lateral positioning and avoid oversedation that could cause maternal hypotension and decreased placental blood flow. 4

Recommended Clinical Approach

Immediate management:

• Reassure the patient that hepatic cysts are common benign findings requiring no intervention. 1, 2
• Document that no follow-up imaging is needed for the hepatic cysts unless symptoms develop. 1, 2
• Advise the patient to report any new symptoms of dysphagia, regurgitation, or chest pain that would warrant gastroenterology evaluation. 4

Symptom-driven approach:

• If abdominal pain or discomfort develops, perform ultrasound first to assess the hepatic cysts for complications. 1, 2
• If esophageal symptoms develop, refer to gastroenterology for consideration of upper endoscopy in the second trimester. 4
• Defer any elective procedures until postpartum when both maternal and fetal risks are eliminated. 4