Diagnostic Ultrasound - Abdomen and Pelvis

Hepatic Cyst
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Diagnoses: Liver
• Adjacent parenchyma may be coarse & hypoechoic
Echinococcal/Hydatid Cyst
• Large, well-defined cystic liver mass with numerous
peripheral daughter cysts
• Cyst within cyst appearance
• Unilocular, multilocular, multiseptated, heterogeneous
• Floating membrane and daughter cysts within
• ±calcification & dilated bile ducts
Biliary Cystadenoma/Cystadenocarcinoma
• Multiseptated cystic mass; enhancing or vascular septations
• More common in women
• May show fine mural or septal calcification
• Mural nodule or papillary excrescence with vascularity
suggests cystadenocarcinoma
• May be associated with dilated biliary ducts
Biloma
• Collection of bile usually associated with biliary tract injury
• Typically symptomatic
PATHOLOGY
General Features
• Etiology
○ Congenital simple hepatic cyst
– Defective development of intrahepatic biliary duct
(IHBD)
• Associated abnormalities
○ ADPLD
– 50% have polycystic kidney disease; M:F = 1:2
– Multiple hepatic cysts of varying size
○ Polycystic kidney disease: 83% have hepatic cysts
○ Tuberous sclerosis
Gross Pathologic & Surgical Features
• Cyst wall: ≤ 1 mm thick
Microscopic Features
• Single unilocular cyst with serous fluid
• Lined by single layer of cuboidal bile duct epithelium
• Surrounding thin rim of fibrous stroma
CLINICAL ISSUES
Presentation
• Most common signs/symptoms
○ Uncomplicated simple cysts & ADPLD
– Usually asymptomatic, detected incidentally
○ Complicated cyst: Pain &/or fever
○ Large cysts may present with symptoms of mass effect
– Abdominal pain (due to capsular distension), jaundice
(due to biliary obstruction), palpable mass
○ Patients with advanced disease of ADPLD may present
with
– Hepatomegaly, liver failure, Budd-Chiari syndrome
• Clinical profile
○ Asymptomatic patient with incidental detection of
simple hepatic cyst on imaging
○ Patients with large hepatic cyst & mass effect: ↑ direct
bilirubin levels
○ Patients with advanced disease of ADPLD: ↑ LFTs
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Demographics
• Age
○ Any age group (usually discovered incidentally in 5th-7th
decades)
○ May slowly increase in size
• Gender
○ M:F = 1:5
• Epidemiology
○ Reported to occur in 2.5% of population
○ Incidence: 1-14% in autopsy series
Natural History & Prognosis
• Complications
○ Hemorrhage, infection, or rupture
○ Large cyst: Compression of IHBD & jaundice
• Prognosis
○ Small & large hepatic cysts: Good prognosis
○ Advanced disease of ADPLD: Good prognosis
Treatment
• Asymptomatic simple hepatic cyst & ADPLD
○ No treatment
• Large, symptomatic, infected hepatic cyst
○ Percutaneous aspiration & sclerotherapy with alcohol
○ Surgical resection or marsupialization
• Advanced disease of ADPLD
○ Partial liver resection, liver transplantation
DIAGNOSTIC CHECKLIST
Consider
• Rule out cyst-like hepatic lesions from infection, neoplasm,
or trauma
Image Interpretation Pearls
• Anechoic, thin wall, posterior acoustic enhancement
• No internal or mural vascularity
• Internal debris may settle under gravity, visible at end of
examination
• If multiple, evaluate kidneys to rule out ADPKD
SELECTED REFERENCES
1. Gevers TJ et al: Diagnosis and management of polycystic liver disease. Nat
Rev Gastroenterol Hepatol. 10(2):101-8, 2013
2. Lantinga MA et al: Evaluation of hepatic cystic lesions. World J Gastroenterol.
19(23):3543-54, 2013
3. Jabłońska B: Biliary cysts: etiology, diagnosis and management. World J
Gastroenterol. 18(35):4801-10, 2012
4. Anderson SW et al: Benign hepatic tumors and iatrogenic pseudotumors.
Radiographics. 29(1):211-29, 2009
5. Mortelé KJ et al: Multimodality imaging of common and uncommon cystic
focal liver lesions. Semin Ultrasound CT MR. 30(5):368-86, 2009
6. Liang P et al: Differential diagnosis of hepatic cystic lesions with gray-scale
and color Doppler sonography. J Clin Ultrasound. 33(3):100-5, 2005
7. 1. Horton KM et al: CT and MR imaging of benign hepatic and biliary tumors.
Radiographics. 19(2):431-51, 1999