Cystic lesions of the liver

INTRODUCTION
Simple

Nonparasytic cystic lesions are uncommon Usually incidentally diagnosed

Prevalence rate about More common women

5%

Types of the cyst

1.simple cyst 2. polysystic liver disease 3. neoplastic cyst 4. traumatic cyst

Simple cyst

Most common Cause of the cyst is development of aberrant intra-hepatic bile ducts in utero 24% are asymptomatic Symptoms are vague like abd.pain/abd.mass/nausia /vomiting/fatigue/jaundice diagnosis:-by usg (90% sensitive),unilocular,anechoic,no septation. CT scan in doubtful cases. Complications:-infection/hemmorhage/rupture

contd

Treatment:Percutaneous aspiration & injection of sclerosing agent ERCP may reveal cystobiliary communications Surgical intervention:- unroofing of the cyst , fenestration,marsupialization. Can be done by laparascopic method or open surgery. Cystic fluid should be sent for cytology, gram staining,culture & biopsy of the wall should be taken Other surgical procedures:-excision of the cyst,antomic hepatic resection,cysenterostomy,liver transplantation(rare)

Adult polycystic liver disease(APLD)

Most frequent extrarenal manifestation of autosomal dominant polycystic renal disease. Isolated APLD Symptoms :-abd. Distension,pain,bowel or biliary obstructions, Complications:- hemorrhage, rupture,infection,portal hypertion,IVC compression, Malignant transformation reported but less common Treatment:-unroofing in pts with small no. of large cyst, if large no, of small cyst then hepatic resection or transplatation

Neoplastic cyst
Types:- biliary cysadenoma & biliary cysadenocarcinoma. Can reach upto a very big size, most common in women in 5th decade of life Symptoms:abd.pain,abd.mass,hepatomegaly,nausia & vomiting Investigation:-usg & CT scan. Neoplastic cyst usually multiloculated or septated or internal papillary projections. Neoplastic cyst should be completely excised in the form of segmentectomy or lobectomy

Traumatic cyst

Common after blunt abdominal trauma but incidence is rare or less. Incidence of traumtic cyst will increase because of nonoperative management of liver injuries Cause:-due to parenchymal injury with disruption of vascular or biliary structures . These cysts have no epithelial lining They appear after days to years after the trauma, Invtn:-usg,Ctscan Treatment:-aspiration ,unroofing or excision

HEPATIC ECHINOCOCCOSIS

Introduction:-Hepatic echinococcosis is endemic in regions where dogs, the primary host for this intestinal tapeworm, are in contact with sheep, elk, or caribou, the intermediate host. Hydatid disease of the liver occurs most commonly in the Mediterranean region, the Middle East, and South America.

pathology
Hydatid disease is caused by the dog tapeworm Echinococcus granulosus, Sheep being the typical intermediate host. Ova are shed in the feces of the hosts and are ingested by the inadvertent intermediate hosts, humans. The ova penetrate the intestinal wall and pass through the portal circulation to enter the liver, where 50% to 75% of cases are reported. From there, they can enter the lungs, the brain, bones, or any other tissues. Echinococcus multilocularis with elk or caribou as the intermediate host causes a hepatic infiltrative, potentially lethal form of the disease.

Gharbis classification:

Gharbi's type I cysts have pure fluid similar to a simple cysts. Type II cysts have a fluid collection with a split-wall floating membrane. Type III cysts have a potentially drainable fluid collection with septa, daughter cysts, or a honeycomb image. Type IV cysts have a heterogeneous echographic pattern. Type V cysts have reflecting thick walls. This same classification may be applied to computed tomography (CT) or magnetic resonance imaging (MRI) scans.

Symptoms & signs

Patients with symptomatic liver hydatid cysts present either with: hepatomegaly, right upper quadrant pain from cyst expansion, or with an acute complication

Complications:Acute complications include obstructive jaundice or cholangitis from rupture into a bile duct, abdominal pain or anaphylaxis from rupture of the cyst into the peritoneal cavity, or productive cough from rupture into the plural cavity and the lung.

INVESTIGATIONS
Traditionally, the Casoni and Weinberg skin tests have been employed to aid in the diagnosis. However, their sensitivity is so low that they are no longer used. The enzyme-linked immunosorbent assay (ELISA) to identify specific antigens and immune complexes has up to a 90% sensitivity depending on the antigen preparation. Complement fixation and indirect hemagglutination test results are positive in 85% to 90% of active cysts. Eosinophilia is present in approximately 40% of patients but is not diagnostic.

IMAGING
Ultrasonography (US) and CT scans :Both studies will show position, size, number of cysts, their proximity to vascular structures, and evidence of extrahepatic cysts. The classic findings for hydatid cysts are thick walls, often with calcifications, and many have daughter cysts. CT scanning may give better information about the location and depth of the cyst than ultrasound.

DIFFERENTIAL DIAGNOSIS
CONGENI HYDATID TAL Number Single or multiple Thin Uniform Usually single Thick Uniform, daughter cysts; 50% calcified AMOEBIC One or few CYSTADE NOMA Single with loculations Variable Septations common; may be irregular

Wall thickness Wall character

Thick Usually uniform

Cyst contents

Usually Clear or clear water bilious; density gelatinous

Red-brown; Usually "anchovy greenpaste" brown; mucinous

MEDICAL THERAPY
Albendazole :-is the drug of choice for medical therapy. However, medical therapy alone for echinococcal cysts has a less than 30% success rate. The response has been shown to be higher in extrahepatic manifestations of the disease and with the alveolar form caused by E. multilocularis. Preoperative treatment with albendazole for at least 3 months has been shown to reduce the recurrence when cyst spillage, partial cyst removal, or biliary rupture has occurred.

SURGICAL THERAPY
Scolecoidal Agents: not preferred now a days due to various complications. hypertonic saline can be used with precautions. many surgeons prefer a meticulous surgical technique rather than over reliance on scolecoidal agents

Open cyst evacuation

Open Cyst Evacuation:. Cysts on the periphery of the liver are easily treatable by open cyst evacuation. .Anterior cysts are best treated through an abdominal approach, . whereas cysts in segments VI and VII may be best approached through a lateral flank approach. .Before entering the cyst, the field is lined with hypertonic saline (20%) soaked gauze in the event of spillage ( Figure 2 ). .The cyst cavity is then opened, and the contents are aspirated with a large suction device that can generate high negative pressure. .Once the contents are aspirated, the cyst can be opened completely, and any remaining debris can be meticulously cleared.

continued
If the cyst is in connection with the bile ducts as shown on preoperative ERCP, intra cavity scolecoidal agents should be avoided. If a connection with the biliary tree is identified, simple closure of the bile duct should be performed using absorbable sutures, and the cyst cavity should be filled with omentum. If the communication cannot be easily closed, external drainage with a closed suction drain or internal drainage with a cystojejunostomy may be warranted.

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Laparoscopic cyst evacuation Pericystectomy Liver resection & transplantation