Cystic Diseases of Liver Dr Anang Pangeni Dr Anang Pangeni Department Of Surgery BPKIHS JR
Introduction• Frequency : not known• Estimated to occur in 5% of the population.• Usually found as an incidental finding on imaging or at the time of laparotomy• Most series in the literature are relatively small, reporting fewer than 50 patients each.
IntroductionA number of different cystic lesions may affect the liver, Pyogenic Liver Abscess Infectious Amebic Liver Abscess Hydatid Liver Cysts Simple hepatic cysts Congenital Polycystic liver disease Cystadenoma Neoplastic Cystadenocarcinoma Traumatic
Pyogenic Liver Abscess• Hippocrates 400BC , and we still debating on what’s the best form of treatment.• Open surgical drainage – recommended treatment for many years.• 1953, McFadzean and associates • advocated closed aspiration and antibiotics for solitary abscess; • however, did not gain widespread acceptance • 1980s, greater acceptance : widespread advancements in Imaging allowing for precise localization and a percutaneous approach to treatment.• Current treatment includes antibiotics, usually with a percutaneous drainage procedure.
Pyogenic Liver Abscess “Appendicitis” as a cause, overwhelmingly described in literature, has now been shifting to other etiologies in modern era. 1. Bile ducts, causing ascending cholangitis; 2. Portal vein, causing pylephlebitis from appendicitis or diverticulitis; 3. Direct extension from a contiguous disease; 4. Trauma due to blunt or penetrating injuries; 5. Hepatic artery, due to septicemia; and 6. Cryptogenic ## 40% of pyogenic liver abscesses of biliary origin are related to an underlying malignancy
Pyogenic Liver Abscess Pathology • Number and Size – solitary and large, • portal, • traumatic, and • cryptogenic hepatic abscesses – multiple and small (and these are usually bilobar!!! Also remember Fungal abscesses) • biliary origin • arterial abscesses • Site – Right lobe : 2/3rd (63%) – Left lobe : 14% – Both lobes : 22% • Organisms – Most common are Gram negative aerobes (50-70%), positive aerobes (55%) and anaerobes. • Biliary : E. cooli , Klebsiella • GIT : klebsiella , E. coli, enterococcus and anerobes • Cryptogenic : anaerobes • AIDS related : Mycobacterium
Pyogenic Liver Abscess Presentation – Subacute and nonspecific • Fever • Malaise • Weight loss , anorexia , nausea vomiting • Chest symptoms when diaphragm is involved • Right upper Quadrant tenderness • Hepatomegaly • Jaundice • Pleural effusion – Acute • Rupture resulting in peritonitis • Septic shock
Pyogenic Liver Abscess Imaging • Ultrasonography and computed tomography (CT) scans - modalities of choice • USG: – Sensitivity : 85% and 90% – Specificity : far less • Aspiration for diagnosis and microbiologic testing usually done. – Troublesome in • morbidly obese • Inhomogenous liver
Pyogenic Liver Abscess Imaging • CT scan – Sensitivity : 95% -100% – better than USG (not limited by air / ribs ) – Hypoattenuated than liver – Wall enhaces on contrast
Pyogenic Liver Abscess Imaging • Plain films – Right lung (33%) • basilar atelectasis or • pleural effusion. – Right diaphragm elevated and less mobile than the left. – Abdomen • usually normal or show only hepatomegaly. • Air-fluid level
Pyogenic Liver Abscess Management • Goals – Treat the abscess – Treat the source • Steps IV antibiotics • Multiple small abscesses Radiological confirmation Drainage • Aspiration and Percutaneous • Surgical
Pyogenic Liver Abscess Management • Antibiotics Alone – Multiple abscesses <1.5cm (Biliary source?) – No concurrent surgical disease • Antibiotics (preferably 6 wk; 2wk may suffice) – Empirical (multidrug) • Aminoglycosides( or Fluoroquinolones) , clindamycin (or Metronidazole)and Ampicillin or Vancomycin – Empirical (single agent) • Ticarcillin-clavulanate • Imipenem-cilastin • Pipercillin – tazobactam – Selective • As per culture reports
Pyogenic Liver Abscess Non –surgical Management • Aspiration alone Vs percutaneous drainage – Higher recurrence (more with biliary source!) – Higher rates of surgical drainage later – Less invasive – Less expensive – Mortality rates similar • Percutaneous drainage (those tails !)not indicated – Large multiple abscesses – Known intrabdominal source – AUO Thus – Ascites SURGERY – Abscess requiring approach Transpleurally
Pyogenic Liver Abscess Surgical Drainage • After Oschner (the man of conservative appendicitis regime !) – Extraperitoneal (see fig.) • Now-a-days indicated in – Failed non operative methods – Requires surgery for underlying source – Multiple macroscopic abscesses – Steroids use – Ascites
Hydatid Cystsechinococcus , Greek, means hedgehog berryhudatid, hudatis, Greek, means a drop of water E. Granulosus (black shade)hydatid ,Latin hydatis, meansdrop of water E. Multilocularis (cross mark)A recent MEDLINE search showed that 86% of articles published on the subject werewritten by surgeons or in association with surgeons, and yet the surgical treatment ofhydatid disease remains controversial!!
Clinical picture• Most commons Asymptomatic (>70%) • Pain in the RUQ or epigastrium • Hepatomegaly and a palpable mass•Non-specific •Dyspepsia •Fever /chills •Jaundice•Signs •RUQ mass •RUQ tenderness
Treatment Complicated Medicaluncomplicated Percutaneous Open Surgical Laparoscopic
Rare but Described in LiteratureSalmonella typhi abscess as a late complication of simple cyst of the liver: A case reportIsmail GOMCEL‹, Ahmet GURER, Mehmet OZDO⁄AN, Nurayd›n OZLEM, Raci AYDIN 1st General Surgery Clinic, Ankara Atatürk Education and Training Hospital, Ankara Abdominal CT showing an abscess cavity (10x5 cm) at the localization of the previous simple liver cyst. This case report emphasizes that simple liver cyst could be infected with Salmonella and progress to a complicated liver abscess, which should respond well to percutaneous catheter drainage and antibiotherapy.
Summary of presentation• Simple cysts – no symptoms but may produce dull right upper quadrant pain if large in size. abdominal bloating and early satiety. – Occasionally, a cyst is large enough to produce a palpable abdominal mass. – jaundice caused by bile duct obstruction is rare, as is cyst rupture and acute torsion of a mobile cyst. – Patients with cyst torsion may present with an acute abdomen. – When simple cysts rupture, patients may develop secondary infection, leading to a presentation similar to a hepatic abscess with abdominal pain, fever, and leukocytosis.• Polycystic liver disease – rarely arises in childhood. – puberty and increase in adulthood. – with PKD. – Women are more commonly affected, and an increase in cyst size and number is correlated with estrogen level. In PCLD, – hepatomegaly may be prominent, and, occasionally, patients progress to hepatic fibrosis, portal hypertension, and liver failure. – Complications, such as rupture, hemorrhage, and infection, are rare. However, patients do present with abdominal pain as the cysts enlarge.
Presentation• Neoplastic cysts – Cystadenoma in middle-aged women; cystadenocarcinoma equally affects both men and women. – Most patients are asymptomatic or have vague abdominal complaints of bloating, nausea, and fullness. – These patients, like all those with hepatic cysts, eventually present with abdominal pain. – Rarely, they present with evidence of biliary obstruction.• Hydatid cysts – most often asymptomatic, but pain may develop as the cyst grows. – Larger lesions typically cause pain and are more likely to develop complications than simple cysts. – a palpable mass in the right upper quadrant. – Cyst rupture is the most serious complication of hydatid cysts. Cysts may rupture into the biliary tree, through the diaphragm into the chest, or freely into the peritoneal cavity. Rupture into the biliary tree may result in jaundice or cholangitis. Free rupture into the peritoneal cavity may cause anaphylactic shock. – secondary infection and subsequent hepatic abscesses.• Hepatic abscesses – present with abdominal pain, fever, and leukocytosis – Those patients with amebiasis can have history of diarrhea and weight loss, – some may be asymptomatic. – Pyogenic abscesses often present with cholangitis, abdominal infections, or sepsis. Rarely, abscesses will rupture, and patients present with peritonitis.
labs• history• a physical examination• imaging study, such as an abdominal CT scan, to define the anatomy of the cyst. – simple hepatic cysts • require little preoperative laboratory workup. • Liver function test results, such as transaminases or alkaline phosphatase, may be mildly abnormal, but bilirubin, prothrombin time, and activated partial thromboplastin times are usually within the reference range. – PCLD, • greater abnormalities in liver function test results are found, but liver failure is uncommon. • Renal function test results, including blood urea nitrogen and creatinine levels, are often abnormal and should be performed on initial evaluation. – hydatid cysts, • eosinophilia is noted in approximately 40% of patients, and echinococcal antibody titers are positive in nearly 80% of patients. – cystic tumors • As with simple cysts, liver function test results are normal • There may be mild abnormalities in some patients. • Carbohydrate antigen (CA) 19-9 levels are elevated in some patients. • Cyst fluid can be sent for CA 19-9 testing at the time of surgery as a marker for cystadenoma and cystadenocarcinoma. – hepatic abscesses • can usually be easily identified by the clinical presentation. • Leukocytosis is generally present. • The enzyme immunoassay (EIA) test detects specific antibodies to E histolytica.
imaging• Before the widespread availability of abdominal imaging techniques, including ultrasonography and CT scans, liver cysts were diagnosed only when they grew to an enormous size and became apparent as an abdominal mass or as an incidental finding during laparotomy. Today, imaging studies often reveal asymptomatic lesions incidentally.• The clinician has a number of options for imaging the liver in patients with hepatic cysts. Ultrasonography is readily available, noninvasive, and highly sensitive. Computed tomography scan (see image below) is also highly sensitive and is easier for most clinicians to interpret, particularly for treatment planning. MRI, nuclear medicine scanning, and hepatic angiography have a limited role in the evaluation of hepatic cysts.Computed tomography (CT) scan appearance of a large hepatic cyst.• Simple cysts have a typical radiographic appearance. They are thin walled with a homogenous low-density interior.• PCLD is confirmed by ultrasound or CT scan with multiple liver cysts identified at the time initial of evaluation, as depicted in the image below.Computed tomography (CT) scan of polycystic liver disease curiously limited to the right lobe.• Hydatid cysts can be identified by the presence of daughter cysts within a thick-walled main cavity, which are clear in the MRI below.Hepatic cysts. Sagittal magnetic resonance imaging (MRI) reconstruction in a patient with a large echinococcal cyst; note daughter cysts in interior.• In patients who are jaundiced with hydatid disease, endoscopic retrograde cholangiopancreatography (ERCP) should be performed to determine if the cyst has ruptured into the bile duct.• Central necrosis of large solid neoplasms can mimic cystic hepatic tumors, as this area of necrosis appears cystic.• Cystadenoma and cystadenocarcinoma usually appear multiloculated with internal septations, heterogeneous density, and irregularities in the cyst wall. The image below is a CT scan of biliary cystadenoma.Computed tomography (CT) scan appearance of biliary cystadenoma.• Unlike many tumors, calcifications are rare in cystadenoma and cystadenocarcinoma.• A practical problem in the evaluation of a patient with a cystic hepatic lesion is differentiating cystic neoplasms from simple cysts.Cystic neoplasms tend to have thicker, irregular, hypervascular walls, whereas simple cysts tend to be thin walled and uniform.• Simple cysts tend to have homogenous low-density interiors, whereas neoplastic cysts usually have heterogeneous interiors with septa and papillary extrusions.• Abscesses of the liver appear cystic on imaging studies, as shown in the image below, but can usually be diagnosed from the overall clinical presentation.Ultrasonographic appearance of a patient with a large simple hepatic cyst.• Previous•