Hepatic cyst with intracystic bleeding: contrast-enhanced sonographic findings

Giant haemorrhagic hepatic cyst with flame-like morphology in a patient with polycystic kidney and liver disease

Introduction

Intracystic haemorrhage is a rare complication of hepatic cysts, and is often mistaken for a malignant lesion.

Case Report

A 55-year-old female with a history of polycystic kidney and liver disease presented with a six-month history of abdominal distension, abdominal pain, early satiety, shortness of breath and 5 kg of weight loss. Imaging revealed a 20 cm mixed solid-cystic hepatic lesion containing peripheral avascular mobile echogenic material with a flame-like morphology. After experiencing symptomatic relief from ultrasound-guided aspiration, the patient underwent cyst fenestration for more definitive treatment.

Discussion

Haemorrhagic hepatic cysts are uncommon and may present on imaging as having lace-like retractile clot, internal layering or shading of separating blood products or avascular mobile flame-like excrescences. The presence of avascular mobile flame-like excrescences appears to be a unique feature of haemorrhagic hepatic cysts.

Conclusion

While haemorrhagic hepatic cysts are rare and commonly mistaken for biliary cystadenomas or adenocarcinomas, the identification of particular features on high-resolution magnetic resonance imaging and contrast-enhanced ultrasound can lead to the correct diagnosis.

Morphological and dynamic evaluation of complex cystic focal liver lesions by contrast-enhanced ultrasound: current state of the art

Complex cystic and cystic-like focal liver lesions (FLLs) encompass a spectrum of disorders ranging from non-neoplastic conditions to benign and malignant tumors. In this prospective, the possibility of non-invasive differentiation of these lesions is extremely important, because the clinical implications and therapeutic strategies vary considerably. Because of its advantageous cost/benefit ratio, widespread availability and easy execution, ultrasound (US) is the first-line imaging modality in most countries for the initial liver survey and represents the imaging technique that usually detects a complex liver cyst. However, US showed poor efficacy in the differential diagnosis of complex cystic FLLs. Thus, for years, computed tomography (CT) and magnetic resonance (MR) imaging have been used for further assessment of these lesions. Recently, the development of low mechanical index real-time contrast-enhanced ultrasound (CEUS) technique performed with the second generation of US contrast agents has led to an accurate depiction of macrovasculature and microvasculature. The technique yields information about contrast enhancement of the liver and FLLs almost as CT and MRI do, but in real time and without the use of ionizing radiation. To date, there is only a small amount of evidence about the role of CEUS in the less common setting of complex liver cysts. The aim of this review is to offer an up-to-date overview on the state of the art of CEUS in the study of the most common complex cystic focal liver lesions. To our knowledge, there are no literature comprehensive reviews on this topic.

Uncommon evolutions and complications of common benign liver lesions

Frequently encountered on abdominal imaging studies, the majority of common benign liver lesions are asymptomatic, confidently diagnosed by imaging, and do not require further workup, follow-up, or treatment. The increasing use of multimodality liver imaging, has allowed the recognition of uncommon evolutions of common benign liver lesions such as size changes, fibrotic regression, and content and vascularization changes, and their complications such as rupture, hemorrhage, thrombosis, extrinsic compression, and malignancy. The purpose of this pictorial review is to describe and illustrate the incidence and diagnostic features of these uncommon evolutions and complications on cross-sectional imaging, mainly on computed tomography and magnetic resonance imaging, with emphasis on those imaging clues which are helpful in the differential diagnosis or indicate the need for treatment.

[Benign non-parasitic hepatic cystic tumours]

Hepatic cystic tumours are a heterogeneous group of diseases with different aetiology and incidence, and with similar clinical signs and symptoms. They are classified as congenital, traumatic, parasitic, or neoplastic cysts. The congenital cystic tumours are the most prevalent, and include the simple cyst and polycystic hepatic disease. Other less common lesions are, hepatic cystadenoma, ciliated embryonic cyst, and a miscellaneous group. We have carried out a review of all benign non-parasitic hepatic cystic tumours, placing special emphasis on therapeutic strategies.

Hemorrhagic hepatic cysts mimicking biliary cystadenoma

The hemorrhagic simple hepatic cyst is extremely rare and can sometimes be confused with biliary cystadenoma or cystadenocarcinoma. Here we present two cases of huge hemorrhagic simple hepatic cysts. Case 1 was a 43-year-old man with a cystic lesion measuring 13 cm × 12 cm in the right hepatic lobe. Ultrasound and computed tomography showed several mural nodules on the irregularly thickened wall and high-density straps inside the cyst. Case 2 was a 60-year-old woman with a huge cyst measuring 15 cm × 14 cm in the central liver. Ultrasound and magnetic resonance imaging showed the cystic wall was unevenly thickened and there were some flame-like prominences on the wall. The iconographic representations of the two cases mimicked biliary cystadenoma. Cystectomy and left hepatectomy were performed for the two patients, respectively. Both patients recovered quickly after their operations and showed no recurrence.