Is it normal to have multiple liver cysts?

Multiple Liver Cysts Are Common and Normal

Yes, having multiple liver cysts is entirely normal and occurs frequently in the general population, with simple hepatic cysts found in 15-18% of patients undergoing abdominal imaging. 1 These benign lesions typically require no treatment or follow-up when asymptomatic. 2

Epidemiology and Clinical Significance

• Simple hepatic cysts affect 5-18% of the population, making them one of the most common incidental findings on abdominal imaging. 3, 1, 4
• Multiple cysts are a normal variant and do not indicate disease unless they meet specific criteria for polycystic liver disease (defined as >10 hepatic cysts). 3
• Even in patients with known cancer, benign liver lesions unrelated to malignancy are found in nearly 30% of cases, emphasizing how common these findings are. 1

When Multiple Cysts Become Clinically Relevant

The number of cysts matters only in specific contexts:

• Polycystic liver disease (PLD) is diagnosed when >10 hepatic cysts are present, typically associated with autosomal dominant polycystic kidney disease (ADPKD) affecting 70-90% of ADPKD patients. 3, 5
• The vast majority of people with multiple liver cysts remain asymptomatic throughout their lives, with only 5% developing symptoms requiring intervention. 4
• Liver cysts, even in advanced PLD, do not usually impact the synthetic or secretory capacity of the liver. 3

Key Imaging Characteristics

Multiple liver cysts are identified by:

• Number of lesions (solitary vs. multiple) and architecture (simple vs. complex) are key descriptive elements on imaging. 3
• On ultrasound, hepatic cysts appear as anechoic (black) lesions with posterior enhancement. 3
• On MRI, cysts show strong signal on T2-weighted sequences and low T1-weighted signal, similar to cerebrospinal fluid. 3
• Simple cysts appear as thin-walled lesions with homogeneous low-density interior on CT. 1

Management Approach

Asymptomatic multiple liver cysts require no treatment or follow-up imaging, regardless of size or number. 2 This is a critical point to avoid unnecessary healthcare utilization.

When to Act:

• Symptoms warrant evaluation: If abdominal pain, early satiety, or mass effect symptoms develop, ultrasound should be the first diagnostic modality. 2
• Complicated cysts require intervention: Features including infection (fever, elevated inflammatory markers), hemorrhage, or compression of adjacent structures necessitate active management. 3, 2
• Infected cysts need antibiotics (fluoroquinolones or third-generation cephalosporins for 4-6 weeks), with drainage considered if cysts are >5-8 cm or fever persists >48 hours despite antibiotics. 2

Common Pitfalls to Avoid

• Do not order routine follow-up imaging for asymptomatic simple cysts, as these benign lesions follow an indolent course without significant changes over time. 2, 1
• Do not assume complex-appearing cysts on suboptimal imaging are malignant or granulomatous without proper characterization—hemorrhage, infection, or proteinaceous content can make simple cysts appear complex. 5
• Treatment success is defined by symptom relief, not volume reduction, so avoid pursuing interventions based solely on cyst size in asymptomatic patients. 2