From the Guidelines
For patients with symptomatic simple hepatic cysts, the most effective treatment approach is volume-reducing therapy, which can be achieved through percutaneous aspiration sclerotherapy or cyst fenestration, as recommended by the EASL clinical practice guidelines 1.
Treatment Options
- Aspiration sclerotherapy: This involves draining the cyst and then injecting a sclerosing agent, such as 100% ethanol, 20% saline, tetracycline, or polidocanol, to reduce the cyst volume. The reported volume reductions after aspiration sclerotherapy range between 76-100%, while symptom relief is obtained in 72-100% of cases 1.
- Cyst fenestration: This procedure involves laparoscopic or open surgery to drain and resect the extrahepatic cyst wall. Laparoscopic and open cyst deroofing/fenestration are associated with a low (<8%) recurrence rate 1.
Considerations
- The choice of treatment depends on the size, location, and number of cysts, as well as the patient's overall health and symptoms.
- Patients with severe symptoms, large cysts, or complications such as infection or hemorrhage may require more aggressive treatment, including surgical intervention or liver transplantation 1.
- The treatment goals are to alleviate symptoms, reduce cyst volume, and improve quality of life, while minimizing the risk of complications and recurrence.
Recommendations
- For symptomatic simple hepatic cysts, percutaneous aspiration sclerotherapy or cyst fenestration should be considered as first-line treatment options 1.
- For patients with polycystic liver disease (PLD), treatment options may include aspiration sclerotherapy, transarterial embolization, laparoscopic cyst fenestration, combined partial hepatectomy and/or cyst fenestration, or liver transplantation, depending on the severity of symptoms and liver phenotype 1.
From the Research
Hepatic Cysts and Pain
- Hepatic cysts are frequently discovered incidentally on abdominal imaging, with a prevalence of 15-18% in the United States 2, 3.
- Although most cysts are benign, some are malignant or premalignant, and it is essential to diagnose cystic lesions to properly manage them 2.
- Simple hepatic cysts are typically saccular, thin-walled masses with fluid-filled epithelial lined cavities, and they can cause abdominal discomfort, pain, distension, and dietary symptoms such as nausea, vomiting, a feeling of fullness, and early satiety 4.
- Complications of simple hepatic cysts include infection, spontaneous hemorrhage, rupture, and external compression of biliary tree or major vessels, which can also cause pain 4.
Diagnosis and Treatment
- Imaging with conventional ultrasound, computed tomography, magnetic resonance imaging, or contrast-enhanced ultrasound can be used to characterize and diagnose hepatic cysts 2, 3, 5.
- Treatment modalities for hepatic cysts include fenestration, aspiration sclerotherapy, or surgical resection, and the choice of treatment depends on the size, location, and symptoms of the cyst 2, 6, 3.
- Asymptomatic simple hepatic cysts do not require treatment, but symptomatic cysts or those suspicious for malignant or premalignant features require treatment 4.
- The American College of Gastroenterology clinical guidelines recommend laparoscopic fenestration for symptomatic simple hepatic cysts due to its high success rate and low invasiveness 4.
Clinical Presentation
- Hepatic cysts can present with non-specific symptoms such as nausea and abdominal pain, and they can occasionally present with symptoms that overlap with gallbladder disease 6.
- The clinical presentation of hepatic cysts can be complicated by the presence of other comorbidities, and imaging studies should be interpreted in the context of the other clinical information for that particular patient 3.