B39. Benign tumors and cysts of the liver

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Benign tumours of the liver

Introduction

For introduction and most common types, see the corresponding pathology 2 topic.

Clinical features

Benign liver tumours are mostly asymptomatic. The most common symptom is upper right quadrant pain but ruptured or haemorrhaging hepatic adenomas may cause haemodynamic instability.

Diagnosis and evaluation

Asymptomatic liver tumours are usually discovered incidentally on ultrasound or CT imaging.

Hepatic haemangioma is diagnosed in the context of characteristic features on ultrasound, no known neoplastic disease, and normal liver function tests. On CT and MRI with contrast there is a characteristic initial discontinuous enhancement followed by subsequent centripetal enhancement. Haemangiomas must not be biopsied due to the high risk of severe bleeding.

FNH is diagnosed when a homogenous lesion with central stellate scar is visualised on ultrasonography, CT, or MRI. FNH lesions which lack one of the three characteristic classic features on imaging is known as “non-classic” FNH. Non-classic FNH requires biopsy for differential diagnosis.

Unlike hepatic haemangioma and FNH, hepatic adenoma is heterogenous on imaging.

Treatment

Surgical removal of hepatic adenoma is usually advised due to the potential complications, along with stopping contraceptive use. Haemangioma and FNH only require treatment if they’re large, symptomatic, or ruptured.

Cysts of the liver

Introduction

For introduction and most common types, see the corresponding pathology 2 topic.

Clinical features

Liver cysts are mostly asymptomatic. The most common symptom is upper right quadrant pain. Ruptured echinococcus cyst may cause anaphylaxis.

Polycystic liver disease is associated with polycystic kidney disease and therefore kidney failure.

Diagnosis and evaluation

Simple liver cysts are easily diagnosed as thin-walled fluid-filled lesions on imaging. The presence of > 20 liver cysts suggest polycystic liver.

Calcified wall on CT, a positive ELISA, and eosinophilia are characteristic features of echinococcus cyst.

Treatment

Simple asymptomatic liver cysts require no treatment.

Echinococcus cysts should be removed surgically. It’s important to remove the whole cyst without spilling its contents, as it could cause anaphylaxis. Antiparasitic treatment with mebendazole may be considered as the only treatment in small cysts, or as a complement to surgery.

Liver abscess

Introduction

For introduction, see the corresponding pathology 2 topic.

Etiology

In many cases, the source cannot be identified (cryptogenic abscess). In cases where the source is identified, the following sources are the most common:

  • Ascending cholangitis (due to biliary obstruction)
  • Bacteraemia
  • Intraabdominal infection (appendicitis, diverticulitis)

Clinical features

The classical features of pyogenic liver abscess are fever, malaise, and pain in the right upper quadrant. They may also have tender hepatomegaly and may develop jaundice if biliary obstruction occurs. There may also be clinical features of the underlying source.

Diagnosis and evaluation

Elevated inflammatory markers, abnormal liver function test, and positive blood culture is often present.

Imaging shows hypoechoic/hypodense lesions, usually in the right lobe of the liver. An underlying source should also be sought on imaging.

Treatment

Treatment includes antibiotics and drainage, as well as identifying the source. Drainage is often percutaneous, but in complicated cases surgical drainage may be necessary.


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B38. Differential diagnosis of jaundice.

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B40. Malignant lesions of the liver and their surgical management

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Surgery – Traumatology

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