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 Table of Contents  
CASE REPORT
Year : 2013  |  Volume : 2  |  Issue : 4  |  Page : 283-285

Intracystic hemorrhage complicating multiple liver cysts


Department of General Surgery, Sri Devaraj Urs Medical College and Research Hospital, Tamaka, Kolar, Karnataka, India

Date of Web Publication7-Feb-2014

Correspondence Address:
N Prathiba
Department of General Surgery, Sri Devaraj Urs Medical College and Research Hospital, Tamaka, Kolar - 563 101, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2278-344X.126755

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  Abstract 

The occurrence of intracystic hemorrhage in benign liver cysts is usually seen in huge solitary cysts in older individuals. Hemorrhage complicating one of the multiple cysts has rarely been reported. We report a case of multiple simple hepatic cysts with intracystic hemorrhage complicating one of the cysts. A 60-year-old woman was admitted with complaints of abdominal discomfort of 6 months duration and abdominal pain with increasing intensity of 2 months duration, not responding to analgesics and was anicteric. On thorough evaluation, a diagnosis of complicated liver cyst was made and her severe symptoms necessitated intervention. Per-operatively, multiple thick walled huge cysts were seen on the surface of the liver. The largest one in the right lobe was complicated by hemorrhage. The cysts were aspirated and deroofed. There were no solid components or biliary communications in the cysts.

Keywords: Biliary cystadenoma, cyst deroofing, intracystic hemorrhage, simple hepatic cyst


How to cite this article:
Kumar K M, Prathiba N, Nischal K. Intracystic hemorrhage complicating multiple liver cysts. Int J Health Allied Sci 2013;2:283-5

How to cite this URL:
Kumar K M, Prathiba N, Nischal K. Intracystic hemorrhage complicating multiple liver cysts. Int J Health Allied Sci [serial online] 2013 [cited 2019 Oct 16];2:283-5. Available from: http://www.ijhas.in/text.asp?2013/2/4/283/126755


  Introduction Top


Hepatic cystic diseases are classified as congenital, traumatic, infectious, neoplastic or parasitic cysts. [1],[2] The complications reported include portal hypertension, [2] obstructive jaundice, [3] rupture, [4] infection [5],[6],[7]] and intracystic hemorrhage. [1],[8],[9],[10],[11] Hemorrhage is usually seen in huge solitary cysts, frequently in older individuals. The overall complication rate is low (10%) of which hemorrhage and infection are the most common. [12] Hemorrhage complicating one of the multiple cysts has rarely been reported. These hemorrhagic liver cysts can mimic biliary cystadenomas or cystadenocarcinoma causing dilemma. We report a case of a patient with hemorrhage complicating one large cyst in the right lobe.


  Case Report Top


This is a case report of a 60-year-old woman, who presented with abdominal discomfort of 6 months duration and abdominal pain, increasing in intensity for 2 months and not responding to analgesics. She had no known comorbidities. On examination, she was normotensive, anicteric and abdominal examination revealed significant hepatomegaly reaching below the umbilicus. Abdominal ultrasound (US) showed a large multiloculated cyst in the liver along with a cortical cyst in the left kidney. On further evaluation, contrast-enhanced computed tomography (CECT) showed presence of multiple cystic lesions involving both the lobes of liver with peripheral enhancement, largest measuring 20 cm × 19 cm × 12 cm in the right lobe [Figure 1]a and b and bilateral multiple corticomedullary cysts, largest measuring 4.7 cm × 4.3 cm × 4 cm in the left kidney. Her liver and renal functions were well-preserved despite the multiple cysts.
Figure 1: (a) Multiple hypodense lesions in both lobes of the liver and left renal cysts; (b) peripheral wall enhancement (arrow)

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Though the possibility of autosomal dominant polycystic kidney disease could not be ruled out, it seemed highly unlikely in the absence of hypertension or any suggestive family history. Though simple cysts do not mandate intervention, her severe symptoms necessitated surgery. Laparotomy and decompression of the cysts was preferred for this complicated hepatic cyst over laparoscopy in view of the large size of the cysts. Per-operatively, multiple thick walled cysts were seen on the surface of the liver. The largest one in the right lobe was complicated by hemorrhage. The cysts were aspirated and deroofed [Figure 2], [Figure 3]a and b. There were no solid components or biliary communication. Histopathology showed fibrocollagenous cyst wall lined with low cuboidal epithelium suggestive of simple cyst.
Figure 2: Multiple large cysts occupying right and left lobe of liver and aspirate reveals intracystic hemorrhage

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Figure 3: (a) Opening of the large cyst in the right lobe; (b) cyst cavity after deroofing

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  Discussion Top


Simple hepatic cysts are commonly solitary, asymptomatic lesions detected incidentally during abdominal imaging/laparoscopy. Simple cysts are formed as the result of excluded hyperplastic bile duct rests. Microscopically, the hepatic cyst wall consists of three layers. [1] The cyst epithelium secretes fluid that may be serous, turbid, or frankly bilious. The epithelial lining may undergo necrosis and sloughing if the intracystic pressure becomes too high leading to intracystic hemorrhage. The prevalence, which is difficult to estimate as most of the asymptomatic cysts go unnoticed, is approximately 3% by US studies [13] and has a female preponderance (4:1). [14] Large cysts tend to occur in older women >50 years of age. Although most patients with liver cysts are asymptomatic, a minority develop symptoms. A dominant cyst may cause pain because of its enlarging size, pressure, or bleeding. The symptoms may include epigastric fullness, abdominal pain, early satiety nausea and vomiting. Symptoms should only be attributed to the cyst when clinically the cyst is large and all other likely clinical diagnoses have been eliminated. [15]

Abdominal US or CECT are the first choice of imaging for symptomatic lesions and are highly accurate for simple liver cysts. [16] Complications such as intracystic bleeding may give rise to diagnostic dilemma as they can mimic biliary cystadenomas/cystadenocarcinomas and should be evaluated carefully. [2] When the diagnosis has been established, wide therapeutic options ranging from no intervention [1] to surgical treatment [17] can be considered. Treatment for simple cysts should be considered only for progressive abdominal pain, or when complications have occurred. Aspiration of cyst fluid followed by sclerotherapy [18] is reasonable for small cysts and it may provide symptom relief in 80% of patients. [19] Simple aspiration is a viable option, but because of the high recurrence rate it is not the preferred method. [20] More definitive treatment options include cyst fenestration (laparoscopic or open) and hepatic resection, which is performed rarely (depending on the size and location of cyst), provide long-term relief in up to 90% of patients. [21],[22],[23] In a study, laparoscopic management of congenital hepatic cysts was considered the gold standard and laparoscopic cyst deroofing/fenestration has produced acceptable long-term results with a minimal morbidity when compared to open surgery. [24] In case of suspicion of hepatobiliary cystadenoma, surgical resection should be performed. Finally, the cyst wall should be subjected to histopathologic analysis to rule out malignancy. A formal hepatic resection is indicated if cystadenoma is diagnosed unexpectedly.


  Acknowledgment Top


The authors would like to acknowledge the support of the Department of Radiology in providing the CECT images and the Department of Pathology for the histopathology.

 
  References Top

1.Kawano Y, Yoshida H, Mamada Y, Taniai N, Mineta S, Yoshioka M, et al. Intracystic hemorrhage required no treatment from one of multiple hepatic cysts. J Nippon Med Sch 2011;78:312-6.  Back to cited text no. 1
    
2.Zhang YL, Yuan L, Shen F, Wang Y. Hemorrhagic hepatic cysts mimicking biliary cystadenoma. World J Gastroenterol 2009;15:4601-3.  Back to cited text no. 2
    
3.Schwed DA, Edoga JK, Stein LB. Biliary obstruction due to spontaneous hemorrhage into benign hepatic cyst. J Clin Gastroenterol 1993;16:84-6.  Back to cited text no. 3
    
4.Egbuna O, Johnson S, Pavlakis M. Rupture of an infected liver cyst into the pericardium in a kidney transplant recipient with polycystic kidney disease. Am J Kidney Dis 2007;49:851-3.  Back to cited text no. 4
    
5.Yoshida H, Onda M, Tajiri T, Mamada Y, Taniai N, Mineta S, et al. Infected hepatic cyst. Hepatogastroenterology 2003;50:507-9.  Back to cited text no. 5
    
6.Yoshida H, Tajiri T, Mamada Y, Taniai N, Kawano Y, Mizuguchi Y, et al. Infected solitary hepatic cyst. J Nippon Med Sch 2003;70:515-8.  Back to cited text no. 6
    
7.Quigley M, Joglekar VM, Keating J, Jagath S. Fatal Clostridium perfringens infection of a liver cyst. J Infect 2003;47:248-50.  Back to cited text no. 7
    
8.Hanazaki K, Wakabayashi M, Mori H, Sodeyama H, Yoshizawa K, Yokoyama S, et al. Hemorrhage into a simple liver cyst: Diagnostic implications of a recent case. J Gastroenterol 1997;32:848-51.  Back to cited text no. 8
    
9.Yoshida H, Onda M, Tajiri T, Mamada Y, Taniai N, Uchida E, et al. Intracystic hemorrhage of a simple hepatic cyst. Hepatogastroenterology 2002;49:1095-7.  Back to cited text no. 9
    
10.Zanen AL, van Tilburg AJ. Bleeding into a liver cyst can be treated conservatively. Eur J Gastroenterol Hepatol 1995;7:91-3.  Back to cited text no. 10
    
11.Takahashi G, Yoshida H, Mamada Y, Taniai N, Bando K, Tajiri T. Intracystic hemorrhage of a large simple hepatic cyst. J Nippon Med Sch 2008;75:302-5.  Back to cited text no. 11
    
12.Murphy BJ, Casillas J, Ros PR, Morillo G, Albores-Saavedra J, Rolfes DB. The CT appearance of cystic masses of the liver. Radiographics 1989;9:307-22.  Back to cited text no. 12
    
13.Mathieu D, Vilgrain V, Mahfouz AE, Anglade MC, Vullierme MP, Denys A. Benign liver tumors. Magn Reson Imaging Clin N Am 1997;5:255-88.  Back to cited text no. 13
    
14.Charlesworth P, Ade-Ajayi N, Davenport M. Natural history and long-term follow-up of antenatally detected liver cysts. J Pediatr Surg 2007;42:494-9.  Back to cited text no. 14
    
15.Reid-Lombardo KM, Khan S, Sclabas G. Hepatic cysts and liver abscess. Surg Clin North Am 2010;90:679-97.  Back to cited text no. 15
    
16.Liang P, Cao B, Wang Y, Yu X, Yu D, Dong B. Differential diagnosis of hepatic cystic lesions with gray-scale and color Doppler sonography. J Clin Ultrasound 2005;33:100-5.  Back to cited text no. 16
    
17.Sanchez H, Gagner M, Rossi RL, Jenkins RL, Lewis WD, Munson JL, et al. Surgical management of nonparasitic cystic liver disease. Am J Surg 1991;161:113-8.  Back to cited text no. 17
    
18.Kairaluoma MI, Leinonen A, Ståhlberg M, Päivänsalo M, Kiviniemi H, Siniluoto T. Percutaneous aspiration and alcohol sclerotherapy for symptomatic hepatic cysts. An alternative to surgical intervention. Ann Surg 1989;210:208-15.  Back to cited text no. 18
    
19.Erdogan D, van Delden OM, Rauws EA, Busch OR, Lameris JS, Gouma DJ, et al. Results of percutaneous sclerotherapy and surgical treatment in patients with symptomatic simple liver cysts and polycystic liver disease. World J Gastroenterol 2007;13:3095-100.  Back to cited text no. 19
    
20.Saini S, Mueller PR, Ferrucci JT Jr, Simeone JF, Wittenberg J, Butch RJ. Percutaneous aspiration of hepatic cysts does not provide definitive therapy. AJR Am J Roentgenol 1983;141:559-60.  Back to cited text no. 20
    
21.Gall TM, Oniscu GC, Madhavan K, Parks RW, Garden OJ. Surgical management and longterm follow-up of non-parasitic hepatic cysts. HPB (Oxford) 2009;11:235-41.  Back to cited text no. 21
    
22.Morino M, De Giuli M, Festa V, Garrone C. Laparoscopic management of symptomatic nonparasitic cysts of the liver. Indications and results. Ann Surg 1994;219:157-64.  Back to cited text no. 22
    
23.Gamblin TC, Holloway SE, Heckman JT, Geller DA. Laparoscopic resection of benign hepatic cysts: A new standard. J Am Coll Surg 2008;207:731-6.  Back to cited text no. 23
    
24.Palanivelu C, Jani K, Malladi V. Laparoscopic management of benign nonparasitic hepatic cysts: A prospective nonrandomized study. South Med J 2006;99:1063-7.  Back to cited text no. 24
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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Introduction
Case Report
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Acknowledgment
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