Intracystic Hemorrhage Required No Treatment from One of Multiple Hepatic Cysts

Successful Coil Embolization of Active Bleeding From a Replaced Left Hepatic Artery to the Left Gastric Artery Associated With a Traumatic Rupture of a Simple Hepatic Cyst Causing Hemodynamic Instability

Intra-abdominal hemorrhage resulting from a ruptured, large hepatic cyst in a polycystic liver disease (PCLD) patient is rare and potentially fatal if not addressed promptly. Only a few isolated cases have previously been reported. The usual patient profile consists of elderly patients on anticoagulation, as is demonstrated in our case. Intra-hepatic cysts are broadly classified into congenital, traumatic, infectious, parasitic, and neoplastic. Congenital intra-hepatic cysts can consist of both simple and PCLD, as is outlined in our case. Simple cysts are usually asymptomatic, but occasionally they may achieve larger dimensions and lead to complications such as rupture, obstruction, infection, hemorrhage, and even portal hypertension. We present an uncommon case of a 78-year-old patient with PCLD on rivaroxaban who presented initially with diffuse abdominal pain, distension, and progression into hemodynamic instability. A computerized tomography (CT) scan revealed a ruptured left hepatic lobe cyst, causing hemoperitoneum and resulting in an acute abdomen. This case was complicated by the patient's anticoagulation status and anomalous hepatic vasculature pattern. Interventional radiology (IR) successfully identified the aberrant bleeding vessel and stopped the active extravasation with super-selective coil embolization.

EASL Clinical Practice Guidelines on the management of cystic liver diseases

The advent of enhanced radiological imaging techniques has facilitated the diagnosis of cystic liver lesions. Concomitantly, the evidence base supporting the management of these diseases has matured over the last decades. As a result, comprehensive clinical guidance on the subject matter is warranted. These Clinical Practice Guidelines cover the diagnosis and management of hepatic cysts, mucinous cystic neoplasms of the liver, biliary hamartomas, polycystic liver disease, Caroli disease, Caroli syndrome, biliary hamartomas and peribiliary cysts. On the basis of in-depth review of the relevant literature we provide recommendations to navigate clinical dilemmas followed by supporting text. The recommendations are graded according to the Oxford Centre for Evidence-Based Medicine system and categorised as 'weak' or 'strong'. We aim to provide the best available evidence to aid the clinical decision-making process in the management of patients with cystic liver disease.

Management of simple hepatic cyst

Simple hepatic cysts are typically saccular, thin-walled masses with fluid-filled epithelial lined cavities that arise from aberrant bile duct cells during embryonic development. With the development of diagnostic modalities such as ultrasonography, computed tomography and magnetic resonance imaging, simple hepatic cysts are seen with relative frequency in daily clinical examination. US is the most useful and noninvasive tool for the diagnosis of simple hepatic cysts, and can generally differentiate simple hepatic cysts from abscesses, hemangiomas and malignancies. Cysts with irregular walls, septations, calcifications or daughter cysts on US should be evaluated with enhanced CT or MRI to differentiate simple hepatic cysts from cystic neoplasms or hydatid cysts.Growth and compression of hepatic cysts cause abdominal discomfort, pain, distension and dietary symptoms such as nausea, vomiting, a feeling of fullness and early satiety. Complications of simple hepatic cysts include infection, spontaneous hemorrhage, rupture, and external compression of biliary tree or major vessels.Asymptomatic simple hepatic cysts should be observed. Treatment for symptomatic simple hepatic cysts includes percutaneous aspiration, aspiration followed by sclerotherapy, and surgery. The American College of Gastroenterology clinical guidelines recommend laparoscopic fenestration based on its high success rate and low invasiveness. Percutaneous procedures for treatment of simple hepatic cysts are particularly effective for the immediate palliation of patient symptoms; however, they are not generally recommended because of the high rate of recurrence.Management of simple hepatic cysts requires correct differentiation from neoplasms and infections, and the selection of a reliable treatment.

Spontaneous rupture of a simple hepatic cyst: report of a case

We describe the spontaneous rupture of a simple hepatic cyst. A 62-year-old woman was admitted for right upper quadrant pain of sudden onset. The patient denied a history of abdominal trauma. Computed tomography of the abdomen showed a 13-cm-diameter solitary hepatic cyst in the right lobe. Part of the cyst surface was irregular, and the internal echo was heterogeneous. Retained fluid was detected under the liver capsule. Ten days after admission, computed tomography revealed that the volume of fluid retained under the liver capsule had decreased but that the hepatic cyst had enlarged again. The patient was referred to our hospital for further evaluation and treatment. Physical examination revealed mild right upper quadrant pain, but no signs or symptoms of peritonitis or abnormalities of the chest or heart. Percutaneous puncture was performed with a needle and an 8-French pigtail catheter under ultrasonographic guidance. Brown serous fluid was aspirated. After the removal of approximately 1,000 mL of fluid, contrast medium was injected to check for communications between the cyst and the biliary tree and to document the absence of leakage into the peritoneal cavity. After complete aspiration of the cyst fluid, 200 mg of minocycline hydrochloride dissolved in 10 mL of saline was injected into the cyst, and the catheter was flushed with 10 mL of saline (total volume of saline, 20 mL). The catheter was then clamped for 30 minutes. After percutaneous aspiration, the patient's symptoms resolved. Minocycline hydrochloride was injected daily for 7 days, and the catheter was removed. There has been no evidence of recurrence after 2 years.

Surgical resection of hepatic cystic echinococcosis impaired by preoperative diagnosis

Cystic echinococcosis (CE) is a rare afferent infectious disease in Japan. This paper reports a case of a hepatic cyst being diagnosed after surgical resection. A 40-year-old Syrian male was admitted for evaluation of a hepatic cyst. Serum antibodies of echinococcosis were negative. Enhanced computed tomography of the abdomen revealed a large cystic lesion, 9 cm in diameter, in the left lateral sector of the liver, which had many honeycomb-like septa and calcified lesions. Magnetic resonance imaging of this lesion revealed high intensity in the T2 weighted image. We preoperatively diagnosed this lesion as cystadenocarcinoma or CE and performed a left hepatectomy. Pathological examination revealed the presence of protoscolices in the fluid of the cysts and led to a diagnosis of this lesion as CE. In conclusion, on seeing patients with huge hepatic cysts who come from an epidemic area, we should consider hepatic CE.

Surgical resection of cystic intraductal papillary adenocarcinoma of the bile duct: report of a case

We describe a cystic intraductal papillary neoplasm of bile duct (IPNB) of adenocarcinoma treated with surgical resection. An 82-year-old man was admitted to our hospital because of distension of the right upper quadrant of the abdomen. On admission, a huge nontender mass was palpated in the right upper abdomen. Initial laboratory tests revealed the following serum values: aspartate aminotransferase, 123 IU/L; alanine aminotransferase, 113 IU/L; alkaline phosphatase, 376 IU/L; bilirubin, 1.6 mg/dL; alpha-fetoprotein, 7.4 ng/mL; CA19-9, 39.8 U/mL; carcinoembryonic antigen, 4.1 ng/mL; and Duke pancreatic monoclonal antigen type 2, 200 U/mL. Abdominal ultrasonography revealed an anechoic mass with an elevated papillary lesion in the right paramedian section. Computed tomography showed a low-density hepatic lesion, measuring 12 × 10 cm, with thick, irregular walls. A T2-weighted magnetic resonance scan showed mural nodules with signal intensity higher than that of the liver. The cystic lesion was suspected to be a cystic IPNB, but we could not determine whether it was a carcinoma. We performed extensive right paramedian sectionectomy and cholecystectomy. The resected multilocular tumor was filled with a yellow fluid, and the cut surface showed multiple, yellowish papillary nodules lining the cystic wall. On histologic examination, the neoplastic biliary epithelium showed papillary growth in the dilated lumen. Papillary and micropapillary lesions exhibited cellular atypia: nuclear enlargement and hyperchromasia, mutilayering, and mitosis. Ovarian-like stroma was not detected. The tumor was diagnosed as an IPNB (carcinoma in situ lesion). These lesions had expanded into several intrabiliary ducts. No recurrence has been detected 2 year after operation.

Hemorrhagic hepatic cyst: report of a case and review of the literature with emphasis on clinical approach and management

OBJECTIVE

Hemorrhage within a hepatic cyst (hemorrhagic hepatic cyst, HHC) is a complication of liver cysts that is difficult to differentiate from other neoplastic entities on imaging. Even when accurately diagnosed, there has been a lack of consensus on the optimal treatment strategy. After presenting our experience with a patient treated via laparoscopy, we aimed to conduct a review of the literature on HHCs.

METHODS

A computerized search in Medline, PubMed, Google Scholar, and The Cochrane Collaboration was carried out for journal articles or abstracts published from 1950 to 2011.

RESULTS

A total of 24 patients with HHCs were identified from 1983 to 2011. The cohort had an even gender distribution with a mean age of 62.7 years. Most patients presented with abdominal pain (80 %), while three (14 %) patients were asymptomatic at the time of presentation. CT imaging and ultrasound were unable to accurately diagnose HHC, whereas hyperintensity on MRI was a reliable diagnostic tool. Three (13 %) patients were managed conservatively with observation. Seven (30 %) patients had percutaneous transhepatic drainage. Among these, two patients experienced recurrence that required repeat treatment. Two (9 %) patients underwent open unroofing of their HHC and one (4 %) laparoscopically, without recurrences. Seven (30 %) patients underwent hepatic resection, whereas six (26 %) patients had a cyst enucleation for their HHCs. All patients had uneventful recoveries, with a mean follow-up of 25 months.

CONCLUSIONS

MRI is a reliable diagnostic tool in the setting of an HHC. Laparoscopic unroofing of HHCs may represent a less morbid and safe treatment modality with low recurrence rates. Given the low level of clinical evidence available so far, these results should be interpreted with caution.