Successful aspiration and ethanol sclerosis of a large, symptomatic, simple liver cyst: Case present

world Journal of Gastroenterology ISSN 1007-9327wjgowjgnet.com92006 The wjG Press. All rights reservedCASE OEORTSuccessful aspiration and ethanol sclerosis of a large,symptomatic, simple liver cyst: Case presentation and reviewof the literatureWojciech C Blonski, Mical S Campbell, Thomas Faust, David C MetzWojciech C Blonski, Division of Gastroenterology, University of literature. World Gastroenterol 2006; 12(18): 2949-2954Pennsylvania, Philadelphia, PA, United States and Department ofGastroenterologyandHepatologyWroclawMedicalUniversityhttp://www.wjgnet079327/12/2949Mical S Campbell, Thomas Faust, David C Metz, Division ofGastroenterology, University of Pennsylvania, Philadelphia, PAUnited StatesCorrespondence to: Dr. David C Metz, 3400 Spruce Street,3 INTRODUCTIONavdin Building, Gastroenterology Division, University of Pennsylvania Health System, Philadelphia, PA 19104,Liver cysts are classified as true or false, depending onUnited States. david metz@uphs. upenn. eduthe presence of an epithelial lining". True cysts includeTelephone:+1-215-6623541lFax:+1-215-3495915congenital cysts(simple cysts and polycystic liver disease)Rece/ved:200503-13 Accepted:2005-07-20parasitic(hydatid) cysts caused by Echinococcus granulosisand multilocularis tapeworms, neoplastic cysts(includingcystadenoma, cystadenocarcinoma, cystic sarcoma,squamous cell carcinoma, and metastatic ovarian,Abstractancreatic. colon, renal and neuroendocrine cancers)Simple liver cysts are congenital with a prevalence of and biliary duct-related cysts(Caroli's disease, bile ductis accurate in distinguishing simple cysts from other caused by spontaneous intrahepatic hemorrhage, post-etiologies, including parasitic, neoplastic, duct-related, traumatic hematoma, or intrahepatic bilomaand traumatic cysts. Symptomatic simple liver cysts areThe pathogenesis of liver cysts is not clear. Simplerare, and the true frequency of symptoms is not known.rer cysts are congenital. They are lined by cuboidalSymptomatic simple liver cysts are predominantly large epithelium and originate from the abnormal development(4 cm), right-sided, and more common in women and of intrahepatic ducts in tera. They are generally stable inolder patlents. the vast majority of simple hepatic cysts size over time, but may slowly enlarge and occasionallyrequire no treatment or follow-up, though large cysts become symptomatic due to mass effect, rupture,4 cm)may be followed initially with serial imaging hemorrhage, or infection. However, an enlarging cystto ensure stability. Attribution of symptoms to a large should prompt consideration of diagnosis other thansimple cyst should be undertaken with caution, after simple cysts. Although simple cysts are generally solitary,alternative diagnoses have been excluded. Aspiration more than one cyst may be present("several solitary ),may be performed to test whether symptoms are due to even in the absence of polycystic liver disease, as is thethe cyst; however, cyst recurrence should be expected, case with the patient described belowLimited experience with both laparoscopic deroofing andWe report herein a case of a patient with a largeaspiration, followed by instillation of a sclerosing agent symptomatic, simple hepatic cyst with resolution ofhas demonstrated promising results for the treatmentof symptomatic cysts. Here, we describe a patient with symptoms immediately after therapy. In addition, wea large, symptomatic, simple liver cyst who experienced present a comprehensive literature review of diagnosis andcomplete resolution of symptoms following cyst drainagetreatment options of symptomatic hepatic cystsand alcohol ablation, and we present a comprehensivereview of the literatureCASE REPORTC 2006 The WJG Press. All rights reserved.A 59-year-old African-American woman was referredrology at the UniversityofKey words: Simple hepatic cyst; Alcohol sclerosis 2 yeal中国煤化工 abdominal pain foraparoscopic deroofingCNMHnt. intermittentssociated with mealsBlonski WC, Campbell MS, Faust T, Metz DC. Successful or bowel movements. Typically, pain would last for one-aspiration and ethanol sclerosis of a large symptomatic, half hour before spontaneously resolving. She had twicesimple liver cyst: Case presentation and review of the presented to the emergency room with abdominal painWwTrw.wignet.com2950ISSN 1007-9327 CN 141219/R World J Gastroenterol May 14, 2006 Volume 12 Number 18Rare compLications of simple liIntracystic haemorrhageInferior vena cava obstructionAdenosquamous carcinomaAdenocarcinomaHepatocellular carinomaCholangiocarcinomaFigure 1 Enhanced abdominal CT scan showing large, simple hepatic cyst.(0.14%-0.17%)4.Morand was discharged without definitive diagnosis. She also patients referred for abdominal ultrasonography, thecomplained of early satiety and occasional nausea without prevalence of simple hepatic cysts has been reportedweight loss.2.5%-4.65%5.6. Liver cysts have been recognizedThe patient was taking daily fiber supplements and had increasingly as the routine use of imaging studieswell controlled with esomeprazole. Hypertension was common in women"and in patients older than 40 yesGegular, daily bowel movements. Reflux symptoms were becomes more widespread. Hepatic cysts may be motreated with metoprolol and amlodipine. Other chronic Symptoms, though quite rare, may be related to themedications were progesterone and estrogen. She denied space-occupying effect of large cysts'and may be morenon-steroidal anti-inflammatory drug usage. Physical common in right-sided cysts Symptoms may includeexamination was unremarkable.abdominal discomfort, chronic right upper quadrant orurinalysis. Screening collonoscop, performed two years reported that among 15 symptomatic patients with solitaryprior to presentation, revealed internal hemorrhoids non-parastic liver cysts, abdominal mass was present inand melanosis. Upon presentation, she underwent 54%, hepatomegaly in 40%, abdominal pain in 33% anddouble contrast upper gastrointestinal examination, jaundice in 9% patientswhich suggested antral gastritis and a hiatal hernia. OnAlthough the natural history of simple hepatic cystssubsequent upper gastrointestinal endoscopy, the mucosa is not well known, complications appear to be quite rareappeared normal, and a medium-sized hiatal hernia was (Table 1). Obstructive jaundice caused by solitary norpresent. Treatment with a proton pump inhibitor, fiber, parasitic liver cyst is rares), and such cysts are usuallyand hyoscyamine failed to improve symptoms by six large and located centrally in the liver, causing compressionmonths.of the hepatic hilum. However, sometimes even smallThe patient underwent abdominal CT scan with hepatic cysts 3 cm in diameter) may cause common bileintravenous and oral contrast, which showed a large(7.7 duct stenosis and intrahepatic biliary dilatationcm) hepatic cyst in the lateral segment of the left lobe, asiver cysts may also cause obstruction of the inferiorwell as several other smaller cysts(Figure 1). Gallstones vena cava, which may lead to massive edema of thewithout gallbladder wall thickening or pericholecystic legs 6, 7) and scrotum 6. Infections of simple hepaticAuid were also visualized On ultrasonography, tenderness cysts with Klebsiella pneumoniae 8l and Escbericbia colt.was elicited specifically over the site of the cyst, which presenting with acute onset of tight upper quadrantmeasured 10.3 cm in its longest dimension.abdominal pain, diarrhea, and fever have also beenAfter several months of expectant management, reported. Other documented complications includethe patient was referred to interventional radiology for intracystic haemorrhage>- and spontaneous rupturedrainage of the large hepatic cyst. Under ultrasonographic Neoplasms arising from solitary non-Parasitic liverguidance, an 8-gauge French catheter was placed into cysts, including primary squamous cell carcinomal4-26the cyst, serous non-bilious fluid was aspirated, and the cystadenocarcinoma, adenosquamous carcinomacatheter was placed to gravity drainage. One week later, adenocarcinoma, hepatocellular carinoma, and cholangioafter drainage had ceased, the patient underwent cthanol carcinoma"-), have been repported, but appear to be verysclerosis. At 4 mo follow-up, the patient was completely rare. A possible association with Peutz-Jeghers syndromesymptom-free. Follow-up ultrasound showed completehascyst resolution中国煤化工d,cT, and MRI areCNMHGcysts(Table 2). LargeDISCUSSIONdiffeand cyst fluid allow for easy recognition of simple cysts byPrevious studies, based on autopsy and surgical series, ultrasound". The ultrasonographic appearance of simpleestimated a very low prevalence of simple non-parasitic cyst is characterized by well-defined, echo-free lesions withwww东教据Blonski WC et al. Aspiration and ethanol sclerosis of simple liver cyst2951Table 2 Radiologic features of simple hepatic cysts3 Alternative explanations for symptoms in patients withhepatic cystsFeacures supporting diagnoslsof a simple cystof a slmple cystAnechoic lesionEchoic lesionThin wallThick wallGastroesophageal refluxAbsence of septationsPresence of septationsPeptic ulcerNo peripheral enhancementon CT/MRIn CT/MRIIrritable bowel syndromeerogeneity within the cystChronic pancreatitisHydatid sandAbdominal wall pain syndromePresence of daughter cystsHeavy wall calcificationssimple cysts should be undertaken with caution afterexcluding alternative diagnoses. Epigastric or rightgood through transmission and an imperceptible wall 4. upper quadrant abdominal pain provoked by eatingThe presence of acoustic enhancement results from may indicate biliary colic, if gallstones are present. arelative lack of absorption and reflection of sound by cyst successful trial of acid suppression therapy points tofluid, as compared with hepatic parenchyma. On Ct gastroesophageal reflux disease. Selected patients mayscan, simple cysts appear as well-demarcated, water-density undergo upper gastrointestinal endoscopy to diagnosesacs,which do not demonstrate peripheral enhancement erosive esophagitis or peptic ulcer disease. Esophageal pHafter intravenous contrast" The presence of septations monitoring can confirm the diagnosis of gastroesophagealsuggests that a cyst is not simple. Occasionally, large simple reflux. If symptoms fluctuate in concert with changes incysts may haveseptations"due to hemorrhage. MRI stool frequency or form, a diagnosis of irritable bowelshows simple cysts as hypointense lesions on T1-weighted syndrome should be suspected. Finally, a diagnosis ofand hyperintense on T2-weighted images. Simple cysts non-ulcer dyspepsia may be entertained in patients withdiffer from cavernous hemangiomas in that they are more unremarkable upper gastrointestinal endoscopy who havehypointense on T1-weighted and of equal hyperintensity continued prominent upper abdominal pain, possibly inon T2-weighted images3. Radiologic characteristics association with nausea and vomiting (Table 3).If thewhich would argue against a cyst being simple include preceding diagnoses can be confidently excluded, thena thick wall, peripheral enhacement on CT or MRI, treatment of a large, symptomatic hepatic cyst may beheterogeneity within the cyst, and an increase in size over undertaken. Treatment options include needle aspirationtime. Hepatic cysts should be differentiated from hepatic with or without injection of sclerosing solution, internalabscesses, hematomas, necrotic metastases, an intrahepatic drainage with cystojejunostomy, wide deroofing, andgallbladder, biliary cystadenoma, and echinococcal(hydatid) different degrees of liver resectioPercutaneous US-or CT-guided needle aspirationRadiologic imaging can accurately identify hydatidof hepatic cysts is asssociated with higth recurrencecysts, with an accuracy of 96% in one series4. Presence rates(78%-100%)53863. Several small case series haveof hydatid sand, internal sepatations, daughter cysts, and demonstrated efficacy for the performance of US- CTheavy wall calcifications argue for Echinococcus granulosis guided needle aspiration of hepatic cysts combined withinfection, instead of a simple cyst Epidemiologic features alcohol injection"l. Because US-guided aspiration withand serology in combination with radiologic imaging ethanol sclerosis is generally safe, effective, and relativelygenerally lead to the correct diagnosis non-invasively.non-invasive, it may be a first-line treatment for selectedCan Distinction between cystic and solid hepatic lesions symptomatic congenital hepatic cysts, especially in patientsbe made accurately by ultrasonography, though CT or with high surgical risk or polycystic liver disease">.TheMR imaging may be more sensitive for the detection of 95%, 96% and 99% alcohol solutions are equally safefocal hepatic masses. The presence of any peripheral and effective 54245! Enough alcohol should be instilledenhancement or thick-walled component suggests the to replace 25% of the aspirated cyst fluid volume".Forpossibility of hepatic abscess or neoplasm. Small hepatic larger cysts( 400 mL), multiple alcohol injections in thelesions with diameter <1 cm are difault to classify Such same sitting have been proposed". Alcohol fixes the cellslesions should be differentiated from benign cysts, hepatic lining the cyst cavity, disabling their ability to secrete fluidmetastases with central necrosis, and microabscesses. In and promote cyst enlargement. Recurrence may occurfollow-up imaging may be considered in selected cases/,order to differentiate small cysts from small metastases, if alcohol does not come in contact with all cells lining thecyst cavityand may be more common in uncooperativeThe vast majority of simple hepatic cysts require no patients. Combinations of percutaneous aspirationreatment. Large cysts(diameter of 4 cm or more)can withbe followed for stability withIf the (pan中国煤化工hphcyst remains unchanged for 2 years, further monitorirC MH Grtonic saline solutionmay be discontinued". Symptomatic or enlarging cysts have also achieved good outcomes.require consideration of alternative diagnoses, includingSeveral recent series have demonstrated good resultscystadenoma, cystadenocarcinoma, and hepatic metastases. for laparoscopic deroofing procedures. Widest possibleIt should be stressed that attribution of symptoms to excision of the cystic wall and concomitant argon beamwww.wignet.com2952ISSN 1007-9327 CN 14-1219/R World J Gastroenterol May 14, 2006 Volume 12 Number 18Table 4 Comparison of treatment options for symptomatic simple liver cystsTreatment optionsAdvantagesObservation aloneBecause most cysts are asymptomatic, intervention is unlikelyOnly effective cyst treatment can prove whetherUS-guidedSimple procedureHigh recurrence rateaspirationMay be used as a diagnostic test to assess whether symptomsare related to the cysteffective forComplications are rareCan not be performed if cyst communicatesEffectivePossible in poor surgical candidatesTechnically feasible and effective in >80% casesMore invasiveImproved results with extensive fenestration and argon beamMorbidity in up to 25%posterior, or deep within hepatic parenchymaVisualization of cyst interior(exclude other diagnoses)Less effective if prior surgery has been attemptedEffectiMost invasiveUseful for cysts with complicationsLonger hospital stays compare to laparoscopyMay perform cystojejunostomy at time of laparotomy for cystsSignificant post-surgical morbiditywith biliary communicationcoagulation or electrocoagulation may improve the cause of symptoms only after systematicludingdurability of results 546. Recurrence has ranged from 0% alternative diagnoses through testing andto 20% with morbidity in 0%to 25%57-60462. In one series, The usual standard of care for patients witlaparoscopic fenestration of simple hepatic cysts was hepatic cysts is observation, but our case demonstratesfound to be technically feasible in 90% with symptomatic that large cysts can occasionally be responsible forrelief in 95% during 38.5 mo follow-up. Careful selection symptoms. In selected cases, symptoms may respond toof patients who have not previouslyundergone surgical cyst treatment. Our treatment approach was ultrasoundtreatment and have large, symptomatic, superficial, and guided aspiration and ethanol sclerotherapy. We believeanterior cysts may improve outcomes". US-or CT-guided that aspiration alone is associated with unacceptably highfenestration in selected cases to assess whether symptoms and radiologic responses were achieved. In the tomaticcyst aspiration can be performed prior to laparoscopic rates of recurrence. In our patient, excellent symare truly referable to the cyst. Reported complications cyst recurrence laparoscopic deroofing may be considered,associated with laparoscopic deroofing include wound though complications may occur in up to 25% of cases.infection, bile leak, chest infection, subphrenic hematoma,and prolonged post-procedure drainage. In selectedcases, an open surgical procedure(fenestration, excision, orREFERENCESresection)may be preferred, despite longer recovery times 1 Taylor BR, Langer B Current surgical management of hepaticand larger surgical scar, because of cyst location, surgeont disease. Ady Surg 1997: 31: 127-148expertise, or the presence of complicating factors &39.61, 3.641. 2 Cowles RA, Mulholland MW. 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Br Surg 1997; 84: 438-444treatment of simple hepatic cysts and polycystic liver disease. 67 Masatsugu T, Shimizu S, Noshiro H, Mizumoto K,Surg Endosc 2003: 17: 623-626Yamaguchi K Chijiiwa K, Tanaka M. Liver cyst with biliary60 Tagaya N, Nemoto T, Kubota K. Long-term results ofcommunication successfully treated with laparoscopiclaparoscopic unroofing of symptomatic solitary nonparasiticderoofing: a case report. SLS 2003; 7: 249-252s- Editor Guo sy L- editor Kumar m E- Editor BiL中国煤化工CNMHGw教据