61g-cystic lesions of the liver

8/3/2019 61G-Cystic Lesions of the Liver

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Cystic lesions of the liver


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INTRODUCTION

Simple Nonparasytic cysticlesions are uncommon

Usually incidentallydiagnosed

Prevalence rate about 5%More common women


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Types of the cyst

1.simple cyst

2. polysystic liver disease

3. neoplastic cyst

4. traumatic cyst


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Simple cyst

Most common Cause of the cyst is development of aberrant

intra-hepatic bile ducts in utero

24% are asymptomatic

Symptoms are vague likeabd.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


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contd

Treatment:- Percutaneous aspiration & injection of sclerosing

agent ERCP may reveal cystobiliary communications

Surgical intervention:- unroofing of the cyst ,fenestration,marsupialization. Can be done bylaparascopic method or open surgery.

Cystic fluid should be sent for cytology, gramstaining,culture & biopsy of the wall should be

taken Other surgical procedures:-excision of the

cyst,antomic hepaticresection,cysenterostomy,livertransplantation(rare)


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Adult polycystic liverdisease(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,IVCcompression,

Malignant transformation reported but lesscommon

Treatment:-unroofing in pts with small no. oflarge cyst, if large no, of small cyst thenhepatic resection or transplatation


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Neoplastic cyst

Types:- biliary cysadenoma & biliarycysadenocarcinoma. Can reach upto a verybig size, most common in women in 5thdecade of life

Symptoms:-abd.pain,abd.mass,hepatomegaly,nausia &vomiting

Investigation:-usg & CT scan. Neoplastic cyst

usually multiloculated or septated or internalpapillary projections.

Neoplastic cyst should be completely excisedin the form of segmentectomy or lobectomy


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Traumatic cyst

Common after blunt abdominal trauma butincidence is rare or less.

Incidence of traumtic cyst will increasebecause 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 thetrauma,

Invtn:-usg,Ctscan

Treatment:-aspiration ,unroofing or excision


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HEPATICECHINOCOCCOSIS Introduction:-Hepatic echinococcosis

is endemic in regions where dogs, theprimary 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 Mediterraneanregion, the Middle East, and SouthAmerica.


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pathology

Hydatid disease is caused by the dog tapewormEchinococcus granulosus,

Sheep being the typical intermediate host. Ovaare shed in the feces of the hosts and areingested 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. Fromthere, they can enter the lungs, the brain, bones,

or any other tissues. Echinococcus multiloculariswith elk or caribou as

the intermediate host causes a hepaticinfiltrative, potentially lethal form of the disease.


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Gharbis classification:-

Gharbi's type I cysts have pure fluid similar toa simple cysts.

Type II cysts have a fluid collection with asplit-wall floating membrane.

Type III cysts have a potentially drainablefluid collection with septa, daughter cysts, ora honeycomb image.

Type IV cysts have a heterogeneousechographic pattern.

Type V cysts have reflecting thick walls. This same classification may be applied to

computed tomography (CT) or magneticresonance imaging (MRI) scans.


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Symptoms & signs

Patients with symptomatic liver hydatidcysts present either with:-

hepatomegaly,

right upper quadrant pain from cystexpansion,

or with an acute complication


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Complications:-

Acute complications includeobstructive jaundice or cholangitisfrom rupture into a bile duct,

abdominal pain or anaphylaxis fromrupture of the cyst into the peritonealcavity, or productive cough from

rupture into the plural cavity and thelung.


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INVESTIGATIONS

Traditionally, the Casoni and Weinberg skintests have been employed to aid in thediagnosis. However, their sensitivity is so lowthat they are no longer used.

The enzyme-linked immunosorbent assay(ELISA) to identify specific antigens andimmune complexes has up to a 90%sensitivity depending on the antigenpreparation.

Complement fixation and indirecthemagglutination test results are positive in85% to 90% of active cysts.

Eosinophilia is present in approximately 40%of patients but is not diagnostic.


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IMAGING

Ultrasonography (US) and CT scans :- Both studies will show position, size,

number of cysts, their proximity tovascular structures, and evidence of

extrahepatic cysts. The classic findings for hydatid cysts are

thick walls, often with calcifications, andmany have daughter cysts.

CT scanning may give better informationabout the location and depth of the cystthan ultrasound.


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DIFFERENTIAL DIAGNOSISCONGENI

TAL

HYDATID AMOEBIC CYSTADE

NOMA

Number Single or

multipleUsually

singleOne or few Single with

loculations

Wallthickness Thin Thick Thick Variable

Wallcharacter

Uniform Uniform,daughtercysts; 50%calcified

Usuallyuniform

Septationscommon;may beirregular

Cystcontents

Usuallyclear water

density

Clear orbilious;

gelatinous

Red-brown;"anchovy

paste"

Usuallygreen-

brown;mucinous


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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 inextrahepatic manifestations of the disease andwith 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 cystremoval or biliar ru ture has occurred.


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SURGICAL THERAPY

Scolecoidal Agents:-

not preferred now a days due to variouscomplications.

hypertonic saline can be used withprecautions.

many surgeons prefer a meticulous

surgical technique rather than overreliance on scolecoidal agents


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Open cyst evacuation

Open Cyst Evacuation:-. Cysts on the periphery of the liver are easily treatable byopen cyst evacuation..Anterior cysts are best treated through an abdominalapproach,. whereas cysts in segments VI and VII may be bestapproached through a lateral flank approach..Before entering the cyst, the field is lined with hypertonicsaline (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 highnegative pressure..Once the contents are aspirated, the cyst can be opened

completely, and any remaining debris can be meticulouslycleared.


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continued

If the cyst is in connection with the bileducts as shown on preoperative ERCP,intra cavity scolecoidal agents should beavoided.

If a connection with the biliary tree isidentified, simple closure of the bile ductshould be performed using absorbablesutures, and the cyst cavity should be

filled with omentum. If the communication cannot be easilyclosed, external drainage with a closedsuction drain or internal drainage with acystojejunostomy may be warranted.


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continued

Laparoscopic cyst evacuation

Pericystectomy

Liver resection & transplantation

61g-cystic lesions of the liver

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