This document discusses cystic diseases of the liver, classifying them into infectious, congenital, neoplastic, and traumatic hepatic cysts. It focuses on infectious cysts including pyogenic liver abscess, amebic liver abscess, and hydatid cyst of the liver. For each condition, it covers epidemiology, etiology, pathology, clinical presentation, diagnosis, treatment including antibiotics, drainage and surgery, and complications. Surgical drainage is currently reserved for patients that have failed nonoperative therapy or those with multiple macroscopic abscesses.

1. CYSTIC DISEASES OF LIVER
BY
DR NIKHIL AMEERCHETTY
Ms general surgery resident
E- mail nikhilameerchetty@gmail.com

2. CLASSIFICATION
1 INFECTIOUS HEPATIC CYSTS
Pyogenic Liver Abcess
Amebic Liver Abcess
Hydatid Cyst Of Liver
2 CONGENITAL HEPATIC CYSTS
Simple cysts
Polycystic liver disease
3 NEOPLASTIC HEPATIC CYSTS
Cystadenoma
Cystadenocarcinoma
4 TRAUMATIC HEPATIC CYST

3. INFECTIOUS HEPATIC CYSTS
 PYOGENIC LIVER ABSCESS
 AMEBIC LIVER ABSCESS
 HYDATID CYST OF LIVER

4. PYOGENIC LIVER ABSCESS
EPIDEMIOLOGY
• The first description of hepatic abcess is credited to Hippocrates in the year 4000BC
• In 1938 ochsner’s classic described this disease
• 5–13 patients per 100,000 admissions prior to 1970,
• 15 cases per 100,000 admissions today.
• This rising incidence is attributed to a more aggressive management approach to hepatobiliary
and pancreatic cancers as well as major improvements in diagnostic imaging.

5. PYOGENIC LIVER ABSCESS
Aetiology
1. Bile Ducts Causing Ascending Cholangitis
2. Portal Vein Pylephlebitis From Appendicitis Or Diverticulitis
3. Direct Extension From The Contagious Disease
4. Trauma Due To The Blunt Or Penetrating Injuries
5. Hepatic Artery Due To Septicaemia
6. Cryptogenic

6. PREDISPOSING FACTORS
• Adult
• Diabetus mellitus
• Cirrhosis
• Chronic pancreatitis
• Peptic ulcer disease
• Inflamatory bowel disease
• Jaundice
• Pyelonephritis
• Malignany
• Children
• Cronic granulomatous disease
• Compliment deficiencies
• Leukemia
• Malignancy
• Sickel cell anemia
• Polycystic liver disease

7. PATHOLOGY
• SOURCE NUMBER SIZE LOCATION
PORTAL SINGLE LARGE RIGHT LOBE
TRAUMATIC USUALLY SINGLE LARGE PREFERENTIAL
CRYPTOGENIC SINGLE LARGE PREFERENTIAL
BILIARY MULTIPLE SMALL BILATERAL
ARTERIAL MULTIPLE SMALL BILATERAL
FUNGAL MULTIPLE MILLIARY BILATERAL

8. CATEGORY OF ORGANISMS % OF PATIENTS
GRAM NEGATIVE AEROBES (BILIARY TREE) 50-70%
ESCHERICHIA COLI 35-45%
KLEBSIELLA
KLEBSIELLA PNEUMONIA
18%
K1 Serotype 60% IN TAIWAN AND KOREAS
PROTEUS 10%
ENTEROBACTER 15%
GRAM-POSITIVE AEROBES 55%
STAPHYLOCOCCAL SPECIES 20%
ANAEROBES (INTESTINAL,CRYPTOGENIC) 40-50%
BACTEROIDES SPECIES 24%
BACTEROIDES FRAGILIS 15%
FUSOBACTERIUM 10%
PEPTOSTREPTOCOCCUS 10%
FUNGAL 26%
ENTEROCOCCUS FAECALIS 10%
BETA-STREPTOCOCCI 5%
ALPHA-STREPTOCOCCI 5%
STERILE (AMEBIC,PARASITIC) 7%

9. CLINICAL PRESENTATION
SYMPTOMS PERCENTAGE
FEVER 83
WEIGHT LOSS 60
PAIN 55
NAUSEA AND VOMITING 50
MALISE 50
CHILLS 37
ANOREXIA 34
COUGH AND PLEURISY 30
PRURITIS 17
DIARRHOEA 12

10. SIGNS PERCENTAGE
RIGHT UPPER QUADRENT TENDERNESS 52
HEPATOMEGALY 40
JAUNDICE 31
RIGHT UPPER QUADRENT MASS 25
ASCITIS 25
PLEURAL EFFUSION OR RUB 20

11. LABORATORY DATA PERCENTAGE
INCREASED ALKALINE PHOSPHATASE 87
WBC COUNT >10,000 71
ALBUMIN <3g/dl 55
HEMATOCRIT <36% 53
BILIRUBIN >2mg/dl 24

12. RADIOLOGY
PLAIN CHEST X RAYS
• Abnormal In 50% Of Patients.
• Elevated Right Hemidiaphragm,
• Right Pleural Effusion,
• Right Lower Lobe Atelectasis)
ABDOMINAL FILMS
• Hepatomegaly
• Air-fluid Levels In The Presence Of Gas-forming Organisms
• Portal Venous Gas If Pylephlebitis Is The Source

13. ULTRASOUND
ADVANTAGES
• Distinguish Solid From Cystic Lesions
• Cost Effective
• Portable.
• 80–95% Sensitive
LIMITATIONS
• Morbidly Obese
• Lesions That Are Located Under The Ribs
• Homogeneous Liver.
COMPUTED TOMOGRAPHY (CT)
• sensitive (95–100%)
• Lesions are detectable to around 0.5 cm
• not limited by shadowing from ribs or air.
cholangiography, often via an indwelling biliary stent, may visualize the abscess

14. TREATMENT
1. ANTIBIOTIC ADMINISTRATION
2. DRAINAGE
3. SURGERY
EXCEPTION
1. Multiple small abcesses
2. Milliary fungal abcesses
• I/V antibiotics
• Antifungals
• No drainage

15. ANTIBIOTICS
• AMINOGLYCOSIDES, CLINDAMYCIN, AMPICILLIN , VANCOMYCIN, FLUOROQUINOLONES AND METRONIDAZOLE
• Single-agent therapy with TICARCILLIN-CLAVULANATE, IMIPENEM-CILASTATIN OR PIPERACILLIN-TAZOBACTAM
• Treatment used to be given for 4–6 weeks
• multiple abscesses <1.5 cm in size and no concurrent surgical disease, patients may be treated with IV antibiotics
alone.
• Candidial infections AMPHOTERICIN B (2-9g)
• FLUCONAZOLE in a dose of 6mg/kg/day is a suitable alternative .

16. ASPIRATION AND PERCUTANEOUS CATHETER
DRAINAGE
• similar mortality rates
• Rate of recurrence
• Patients in whom percutaneous drainage is not appropriate include those patients with
(1) multiple large abscesses
(2) known intra-abdominal source that requires surgery
(3) an abscess of unknown etiology
(4) ascites
(5) abscesses that would require transpleural drainage.

17. SURGICAL DRAINAGE
• Traditional approach :
Extraperitoneally via a 12th-rib resection to avoid contamination of the peritoneal cavity.
• Newer concept
Transperitoneal surgical exploration
• Advantages
(1) treat the inciting pathology in the remainder of the abdomen/pelvis
(2) gain access and exposure of the entire liver for evaluation and treatment
(3) access the biliary tree for cholangiography and bile duct exploration
Surgical drainage is currently reserved for patients that have
• Failed Nonoperative Therapy,
• Those With Multiple Macroscopic Abscesses,
• Those On Steroids,
• Concomitant Ascites.

18. COMPLICATIONS
• Up to 40% of patients develop complications from pyogenic liver abscesses
• Generalized Sepsis (Most Common)
• Pleural Effusions
• Empyema
• Pneumonia
• Perihepatic Abscess
• Hemobilia
• Hepatic Vein Thrombosis.

19. FACTORS ASSOCIATED WITH POOR OUTCOME
Failure To Establish A Diagnosis
Inability To Achieve Adequate Drainage
Diabetes mellitus
Associated malignancy
Multiple abscesses
Septicemia

20. AMEBIC LIVER ABSCESS
• Amebic liver abscess is caused by the parasitic protozoan Entamoeba histolytica.
• First described by Hippocrates and other associates in 5tH century BC
• Second only to malarial disease as a cause of protozoan-mediated death.

22. PATHOLOGY
• 90% of people are asymptomatically colonized,
• Incubation takes 1–4 weeks.
• invasive disease is colitis
• Licqufied hepatic parenchyma with debris and blood – ANCHOVY SAUSE
• 70–80% diarrhea, abdominal pain, weight loss, and stools consisting of blood and
mucus.
• "buttonhole" ulcers with undermined edges.
• The most common extraintestinal site of amebiasis is the liver, occurring in 1–7% of
children and 50% of adults

23. Symptom Percentage
Pain 90
Fever 87
Nausea and vomiting 85
Anorexia 50
Weight loss 45
Malaise 25
Diarrhoea 25
Cough and pleurisy 25
Pruritis <1
CLINICAL PRESENTATION

24. Sign Percentage
Hepatomegaly 85
Right upper quadrant
tenderness
84
Pleural effusion or
rub
40
Right upper quadrant
mass
12
Ascitis 10
Jaundice 5

25. Laboratory Percentage
Increased alkaline phosphatase 80 in cronic cases
Wbc count >10000 70
Hamatocrit <36% 49
Albumin <3g/dl 44
Bilirubin >2mg/dl 10
Stool samples 40-50%

26. DIAGNOSIS
• The Definitive Diagnosis Of Amebic Liver Abscess Is By E. Histolytica
Trophozoites In The Pus
• Detection Of Serum Antibodies To The Ameba.

27. DISTINGUISHING CLINICAL CHARECTERISTICS
AMEBIC PYOGENIC
Age <50yrs Age >50yrs
M:F 10:1 M:F 1.5:1
PAIN FEVER
DIARROHEA JAUNDICE,PRURITIS
ABDOMINAL TENDERNESS PALPABLE MASS
RECENT H/O TRAVEL TO ENDEMIC AREA NO HISTORY
PULMONARY COMPLICATIONS MALIGNANCY

28. RADIOLOGY
• Chest radiographs
 pleural effusion
 infiltrates
 elevated hemidiaphragm.
• Ultrasound, CT, and magnetic resonance imaging (MRI)
 Excellent but are nonspecific.19
 In 75–80% of cases, only a single abscess is present and in the right lobe
 10% are in the left lobe
 The mean resolution time is 7 months, and 70% have findings that persist for more than 6
months.

29. TREATMENT
• Since the introduction of metronidazole in the 1960s, surgical drainage of
amebic liver abscesses has become virtually unnecessary

30. ANTIBIOTICS
• Noninvasive infections can be treated with paromomycin.
• Nitroimidazoles, especially metronidazole, are the mainstays of treatment for invasive amebiasis.
• This antibiotic crosses the placenta and blood-brain barrier and is contraindicated in the first trimester of
pregnancy.
• Positive responses to metronidazole should be seen by the third day of treatment.
• nitroimidazole treatment should be followed with paromomycin or diloxanide furoate to cure luminal
infection

31. THERAPEUTIC ASPIRATION
• Drainage should be considered in patients that have no clinical response to drug therapy within 5–7
days
• those with a high risk of abscess rupture defined as having a cavity >5 cm in diameter
• by the presence of lesions in the left lobe.
• Bacterial coinfection of amebic liver abscess has been observed

32. PERCUTANEOUS DRAINAGE
• Most useful for treating pulmonary, peritoneal, and pericardial
complications.
• The high viscosity of amebic abscess fluid, requires a large
diameter catheter for adequate drainage.

33. SURGICAL
• Failed To Respond To Conservative Therapy (Most Common Indication).
• Laparotomy Is Indicated For Life-threatening Hemorrhage
• When The Amebic Abscess Erodes Into A Neighboring Viscus
• Sepsis Due To A Secondarily Infected Amebic Abscess

34. COMPLICATIONS
• Complications from amebic abscesses occur secondary to rupture of the abscess into the peritoneum,
pleural cavity, or pericardium (Fig 28–7). incidence 2–17% ,mortality rates between 12% and 50%.23
SEQUELAE
• Thoracic amebiasis (empyema, bronchohepatic fistulas, and pleuropulmonary abscess) is the most
common complication,
• Pericardial amebiasis (acute pericarditis with tamponade).
• Pleural cavity drainage of the pleural cavity with tube thoracostomy.
• Bronchi, Surgical intervention is not required,
• Cerebral amebiasis - seizures.

35. OUTCOME
Increased age
Increased bilirubin level >3.5mg/dl
Pulmonary involvement
Rupture or extension
Late presentation

36. HYDATID LIVER CYST
• E. granulosus and
• E. multilocularis
• Zoonosis
• Humans are accidental intermediate hosts, whereas animals can be both
intermediate hosts and definitive hosts.
• In humans, 50–75% of the cysts occur in the liver,
• 25% are located in the lungs, and
• 5–10% distribute along the arterial system

38. LIFE CYCLE OF ECHINOCOCCUS GRANULOSUS.• parasite lives in the proximal small bowel
• Eggs are released into the host's intestine
• excreted in the feces
• humans are the intermediate host
• ingest the ovum
• The ovum loses the protective chitinous layer and is digested in the duodenum
• The released hexacanth embryo (oncosphere) passes through the intestinal wall into the portal circulation
and develops into cysts within the liver

39. Pathology
PERICYST,
ECTOCYST
ENDOCYST IS THE GERMINAL MEMBRANE
BROOD CAPSULES
PROTOSCOLECES
A PROTOSCOLEX.
ADULT TAPE WORM DAUGHTER CYST
endogenic vesiculation.
Ectogenic vesiculation

40. CLINICAL PRESENTATION
Symptoms Percentage
Asymptomatic 75
Abdominal pain 20
Dyspepsia 13
Fever and chills 8
Jaundice 6

41. signs percentage
Right upper quadrent mass 70
Right upper quadrent tenderness 20
Laboratory data percentage
Eosnophilia 35
Bilirubin > 2mg/dl 20
Wbc count<10,000 10
Elisa 90
Arc 5 91

42. RADIOLOGY
CHEST X RAYS
• Elevated diaphragm
• concentric calcifications in the cyst wall
• ULTRASOUND
• Specificity- approx 90%
• hydatid sand,daughter cyst,unilocular & calcified cyst wall
• Internal structure,number,and location of the cysts and the presence of complication

43.  Type I has a pure fluid collection
 Type II has a fluid collection with a split wall (floating membrane)
 Type III reveals a fluid collection with septa (honeycomb image)
 Type IV has heterogenous echographic patterns
 Type V has reflecting thick walls(dead calcified wall)
GHARBI’S CLASSIFICATION

44. COMPUTED TOMOGRAPHY
• specific information about the location
• depth of the cyst within the liver
MRI
• structural details of the hydatid cyst
Endoscopic retrograde cholangiopancreatography (ERCP)
• communication between the cysts and bile ducts

45. DIFFERENTIAL IMAGING AND CHARACTER OF
HEPATIC CYSTS
Pyogenic Amoebic Hydatid
Number Single or
multiple
One or few Usually single
Wall character Uniform or
multiloculated
Usually
uniform
Uniform, daughter
cysts; 50%
calcified
Cyst contents Usually pus Red-brown;
like anchovy
paste
Clear or bilious;
gelatinous

46. TREATMENT
PRINCIPLES
(1) Eradication Of The Parasite Within The Cyst
(2) Protection Of The Host Against Spillage Of Scoleces,
(3) Management Of Complications.

47. METHODS
• Medical
• Percutaneous
• surgical

48.  Medical treatment
 Success rate of 30%
-Albendazole (10-15mg/kg/day) is drug of choice
- decreases the size of cyst
- decreases intracystic pressure
- decreases risk of rupture
Mebendazole (50mg /kg)& Praziquantel ( 50mg/kg)
Indications
Small cysts (<4 cm) located deep in the
parenchyma of the liver
TREATMENT

49. PERCUTANEOUS ASPIRATION AND DRAINAGE
• Surgical dictum
• “ PERCUTANEOUS PUNCTURE OF A HYDATID CYST IS A DANGEROUS AND CONTRAINDICATED “
• 1983, Fornagechallenged this axiom
• FREQUENTLY USED PROTOSCOLICIDAL AGENTS
• 15–20% Saline
• 95% Ethanol
• A Combination Of 30% Saline And 95% Ethanol,
• Mebendazole Solution.
 The PAIR technique (percutaneous aspiration, injection and re-aspiration) has also been combined with
albendazole therapy with 70% success rate

50. SURGERY
• OBJECTIVES
• (1) Inactivate The Scoleces
• (2) Prevent Spillage Of Cyst Contents
• (3) Eliminate All Viable Elements Of The Cyst
• (4) Manage The Residual Cavity Of The Cyst.

51. • Preparation
• Give 4-6 week of albendazole tablet before surgery (800mg/day in divided doses) in adult
• Pre operative visualization of biliary tract by ERCP.
• Anaesthesist warned of sudden anaphylactic shock in case of spillage.
SURGERY

52. Open surgery
partial pericystectomy+ omentopexy
partial pericystectomy+ capittonage
Laparoscopic surgery
partial pericystectomy + omentopexy

53. TREATMENT OPTIONS FOR HYDATID CYSTS
Uncomplicated cysts
Percutaneous or laparoscopy
Gharbi type I or II
Anterior cysts
Peripheral cyst
Small cyst
No or minimal calcification
Open surgery
Gharbi type IV or V
Posterior cyst
Central cyst
Large cyst
Heavy calcification
Complicated cysts
Open surgery
Biliary communication
Pleural communication
Peritoneal rupture

54. • Rupture into CBD causing obstructive jaundice
• Anaphylactic shock
• Rupture into peritoneal cavity
• Rupture into lung
COMPLICATIONS OF HYDATID CYST

55. •THANK YOU