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Cystic Lesions Of The Liver

Cystic Lesions Of The Liver

1. Simple liver cysts

Are simple cysts of the liver dangerous?

They are thin-walled, septa-free, fluid-filled balloon-like lesions of different sizes in the abdomen. It is generally accepted to be congenital. Its incidence increases in women and with age. They are not cancerous, nor are they dangerous. It is detected on most ultrasounds or computed tomography, does not cause symptoms and does not require treatment.

What are the symptoms of simple cysts of the liver?

Some cysts can grow large enough to cause pain and a feeling of fullness in the upper right side of the abdomen.

Do simple cysts of the liver need to be treated?

Large (>5 cm) cysts that cause complaints and are suspected of neoplasia in radiological findings require surgical treatment. The treatment method of choice is to open a large window in the cyst wall (unroofing) open or laparoscopically. In the meantime, the contents of the cyst can be aspirated and the epithelium lining the cyst can be burned with argon cautery.

Is it possible to drain simple cysts of the liver from the outside with a needle?

It is possible, but aspirating the cysts in this way and draining their contents results in the cyst filling again in half of the patients. For this reason, it is not preferred as a therapeutic method.

2. Mucinous cystic neoplasia (Cystadenoma)

Are cystadenomas of the liver dangerous?

The risk of a malignant transformation is around 15%. Rare cystic tumors and large sizes in most patients require surgical treatment.

How are cystadenomas of the liver diagnosed?

The general features of ultrasound are in the form of a hypoechoic lesion with thick and irregular walls, nodular structures extending into the debris and lumen. Tissue evidence is required for a definitive diagnosis.

Can simple cysts and cystadenomas of the liver be confused?

A simple cyst that bleeds into it and becomes complicated can be considered as a cystadenoma. However, when cystadenomas are visualized on CT as a low-density, thick-walled lesion with septations, they can be easily differentiated in simple liver cysts.

What is the treatment for cystadenomas of the liver?

Due to the risk of malignancy, it is recommended to completely remove cystadenomas together with the surrounding liver tissue.

Partial removal of the cyst is not recommended. Because, in such a procedure, there is both a risk of recurrence and a risk of leaving malignant tissue behind.

3. Polycystic liver disease

What is polycystic liver disease?

It is a genetic disease that affects the liver and kidney. Cysts consist of bile epithelium, which is structured in the form of a bunch of grapes and has no relationship with the bile ducts. As a result of excessive growth of the epithelium and accumulation of fluid, a dimensional increase in cysts can be observed. The disease may also be accompanied by aneurysm and artery dissection in the head.

What are the symptoms of polycystic liver disease?

In most patients, it does not cause any symptoms and does not require treatment. However, the liver that is irradiated due to growing cysts may cause complaints in the patient by putting pressure on neighboring organs.

In which cases is polycystic liver disease required treatment?

Complications such as infection or bleeding into the cyst may develop. Depending on the severity of the pressure due to cysts, there is a wide range of treatment from fenestration to liver transplantation in patients with complaints. Fenestration is the process of opening a window in the cyst wall. It can be applied by open or laparoscopic surgical method.

In some patients whose liver is very large and there are many cysts, it may be considered to reduce the pressure by removing a part of the liver together with the phenetration process (hepatectomy). In cases where cysts completely cover the liver and cause failure, liver transplantation may also be considered.

4. Parasitic cysts (Hydatid cyst)

Why do hydatid cysts occur, what is the causative agent?

Hydatid cysts are caused by Echinococcus granulosus (EG). It is transmitted by dogs. The disease is common in endemic areas where agriculture and animal husbandry are carried out. Poor hygienic conditions facilitate the spread of infection. Echinococcus Alveolaris (EA),on the other hand, is a parasite from the same family, but it is detected in the liver as a solid mass, not a cyst. EA, which is more common in the Central Anatolia region, mimics malignant tumors of the liver. A biopsy from the mass is diagnostic.

What can be done in the treatment of hydatid cysts?

The primary treatment of hydatid cysts due to EG is surgery.

Drug (albendazole) treatment can be started for patients who cannot undergo surgery. In addition, drug administration can be chosen as the first treatment in small-sized cysts. In large cysts, 30% of the cysts disappeared (cure),30-50% of the cysts decreased in size, and no change was observed in 20% of them.

In addition to these, the PAIR method can also be used in suitable patients (Puncture, Aspiration, Injection, and Reaspiration). Patients suitable for PAIR are those with Type I and II cysts. This method has a short hospital stay and low cost.

Which patients are not eligible for PAIR?

Patients with honeycomb-like hydatid cysts located on the surface of the liver or associated with the biliary tract are not suitable candidates. In these, there are risks such as the spread of cyst content, the development of an anaphylactic reaction, and the occurrence of bile leaks.

Are there any conditions that do not require treatment?

Yes. If radiological examinations show that the cyst wall is covered with calcium (Type V cyst),treatment is not required for these cysts. Calcific cysts are considered to lose their vitality.

What are the problems that hydatid cysts will cause when growing?

As hydatid cysts grow, they can cause erosion in the bile ducts around them and cause them to open. In this case, the contents of the cyst drain into the bile ducts and cause obstructive jaundice. It is a difficult and complicated condition and both surgical and endoscopic interventions may be required for its treatment.

What are the stages in the surgical treatment of hydatid cysts?

The aim of surgical treatment is to safely remove the contents of the infectious cyst from the body. In the event that the contents of the cyst spread into the abdomen, there is a risk of both anaphylaxis and the formation and growth of new cysts wherever the fluid comes into contact.

The use of albendazole is recommended for 5-7 days before surgery to prevent the risk of transmission of cyst fluid to surrounding tissues during surgery. Also, in the neck of the operation, the area around the cyst is covered with compresses saturated with scolocidal agents (povidone, iodine or hypertonic NaCl).

After the cyst fluid is drained, the cyst wall visible on the surface of the liver is cut and the germinative membrane and daughter vesicles inside are cleaned. By reviewing the cyst walls, it is determined whether there is a relationship with the bile ducts. Then, if possible, the cyst cavity is filled with the omentum.

5. Pyogenic Liver Abscess

What causes a pyogenic liver abscess?

The most common cause is aggressive surgical and interventional procedures performed in elderly and frail patients with biliary tract or pancreatic cancer. Those who use intravenous drugs and those who undergo ablation (RFA) for tumors in the liver are also in the risk group. Abscess development is also seen as a result of blood-borne contamination from intra-abdominal microbial foci such as diverticulitis and gangrenous cholecystitis to the liver. In most diabetics and 20% of patients with impaired immune systems, the cause cannot be determined.

Is a pyogenic liver abscess dangerous?

Yes. The risk of death is around 15%. The risk of death increases even more in the presence of delay in diagnosis, malnutrition and multiple abscesses.

What are the symptoms of a pyogenic abscess?

Symptoms such as fever, weakness, chills, jaundice, loss of appetite, weight loss, nausea can be seen.

How is a pyogenic abscess diagnosed?

After detection in ultrasound or computed tomography, the diagnosis is confirmed by the presence of microbial growth in the sample taken from the abscess and/or in the blood culture.

How to treat a pyogenic abscess in the liver?

It is treated by using antibiotics intravenously and draining the abscess. In addition, the underlying cause should be investigated and eliminated. The risk of death is around 15%. The risk of death increases even more in the presence of delay in diagnosis, malnutrition and multiple abscesses.

6. Amoeba abscess in the liver

What causes amoeba abscess?

It develops as a result of the spread of amoeba trophozoites that exceed the large intestine wall to the liver through the blood. Its incidence is 7-12 times higher in men than in women. It is more common in developing countries (Mexico, India, Central and South America, tropical regions of Asia and Africa).

How is an amoeba abscess diagnosed?

Diagnosis is based on imaging and serological tests in the blood. It is not necessary to take a sample of abscess fluid to make a diagnosis. The detection of Entamoeba antibodies (EIA) in the blood sample has high sensitivity (>94%) and specificity >(95%) in the diagnosis of amoebic liver abscesses.

How to treat an amoeba abscess in the liver?

Antiprotozoal drug therapy is the mainstay of treatment. In general, drainage is not required. Drainage is only necessary if there is a risk of rupture of the abscess, if it is important to distinguish whether the abscess is pyogenic or amoeba-induced, or if there is no clinical response despite 5-7 days of antiprotozoal therapy.

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Prof. Dr. Sedat KarademirProf. Dr. Sedat KarademirGeneral Surgery Specialist
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