Post on 06-Apr-2018
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Cystic lesions of the liver
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INTRODUCTION
Simple Nonparasytic cysticlesions are uncommon
Usually incidentallydiagnosed
Prevalence rate about 5%More common women
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Types of the cyst
1.simple cyst
2. polysystic liver disease
3. neoplastic cyst
4. traumatic cyst
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Simple cyst
Most common Cause of the cyst is development of aberrant
intra-hepatic bile ducts in utero
24% are asymptomatic
Symptoms are vague likeabd.pain/abd.mass/nausia/vomiting/fatigue/jaundice
diagnosis:-by usg (90%sensitive),unilocular,anechoic,no septation.CT scan in doubtful cases.
Complications:-infection/hemmorhage/rupture
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contd
Treatment:- Percutaneous aspiration & injection of sclerosing
agent ERCP may reveal cystobiliary communications
Surgical intervention:- unroofing of the cyst ,fenestration,marsupialization. Can be done bylaparascopic method or open surgery.
Cystic fluid should be sent for cytology, gramstaining,culture & biopsy of the wall should be
taken Other surgical procedures:-excision of the
cyst,antomic hepaticresection,cysenterostomy,livertransplantation(rare)
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Adult polycystic liverdisease(APLD) Most frequent extrarenal manifestation of
autosomal dominant polycystic renal disease. Isolated APLD Symptoms :-abd. Distension,pain,bowel or
biliary obstructions, Complications:- hemorrhage,
rupture,infection,portal hypertion,IVCcompression,
Malignant transformation reported but lesscommon
Treatment:-unroofing in pts with small no. oflarge cyst, if large no, of small cyst thenhepatic resection or transplatation
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Neoplastic cyst
Types:- biliary cysadenoma & biliarycysadenocarcinoma. Can reach upto a verybig size, most common in women in 5thdecade of life
Symptoms:-abd.pain,abd.mass,hepatomegaly,nausia &vomiting
Investigation:-usg & CT scan. Neoplastic cyst
usually multiloculated or septated or internalpapillary projections.
Neoplastic cyst should be completely excisedin the form of segmentectomy or lobectomy
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Traumatic cyst
Common after blunt abdominal trauma butincidence is rare or less.
Incidence of traumtic cyst will increasebecause of nonoperative management of
liver injuries Cause:-due to parenchymal injury with
disruption of vascular or biliary structures .
These cysts have no epithelial lining
They appear after days to years after thetrauma,
Invtn:-usg,Ctscan
Treatment:-aspiration ,unroofing or excision
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HEPATICECHINOCOCCOSIS Introduction:-Hepatic echinococcosis
is endemic in regions where dogs, theprimary host for this intestinal
tapeworm, are in contact with sheep,elk, or caribou, the intermediate host.Hydatid disease of the liver occurs
most commonly in the Mediterraneanregion, the Middle East, and SouthAmerica.
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pathology
Hydatid disease is caused by the dog tapewormEchinococcus granulosus,
Sheep being the typical intermediate host. Ovaare shed in the feces of the hosts and areingested by the inadvertent intermediate hosts,
humans. The ova penetrate the intestinal wall and pass
through the portal circulation to enter the liver,where 50% to 75% of cases are reported. Fromthere, they can enter the lungs, the brain, bones,
or any other tissues. Echinococcus multiloculariswith elk or caribou as
the intermediate host causes a hepaticinfiltrative, potentially lethal form of the disease.
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Gharbis classification:-
Gharbi's type I cysts have pure fluid similar toa simple cysts.
Type II cysts have a fluid collection with asplit-wall floating membrane.
Type III cysts have a potentially drainablefluid collection with septa, daughter cysts, ora honeycomb image.
Type IV cysts have a heterogeneousechographic pattern.
Type V cysts have reflecting thick walls. This same classification may be applied to
computed tomography (CT) or magneticresonance imaging (MRI) scans.
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Symptoms & signs
Patients with symptomatic liver hydatidcysts present either with:-
hepatomegaly,
right upper quadrant pain from cystexpansion,
or with an acute complication
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Complications:-
Acute complications includeobstructive jaundice or cholangitisfrom rupture into a bile duct,
abdominal pain or anaphylaxis fromrupture of the cyst into the peritonealcavity, or productive cough from
rupture into the plural cavity and thelung.
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INVESTIGATIONS
Traditionally, the Casoni and Weinberg skintests have been employed to aid in thediagnosis. However, their sensitivity is so lowthat they are no longer used.
The enzyme-linked immunosorbent assay(ELISA) to identify specific antigens andimmune complexes has up to a 90%sensitivity depending on the antigenpreparation.
Complement fixation and indirecthemagglutination test results are positive in85% to 90% of active cysts.
Eosinophilia is present in approximately 40%of patients but is not diagnostic.
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IMAGING
Ultrasonography (US) and CT scans :- Both studies will show position, size,
number of cysts, their proximity tovascular structures, and evidence of
extrahepatic cysts. The classic findings for hydatid cysts are
thick walls, often with calcifications, andmany have daughter cysts.
CT scanning may give better informationabout the location and depth of the cystthan ultrasound.
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DIFFERENTIAL DIAGNOSISCONGENI
TAL
HYDATID AMOEBIC CYSTADE
NOMA
Number Single or
multipleUsually
singleOne or few Single with
loculations
Wallthickness Thin Thick Thick Variable
Wallcharacter
Uniform Uniform,daughtercysts; 50%calcified
Usuallyuniform
Septationscommon;may beirregular
Cystcontents
Usuallyclear water
density
Clear orbilious;
gelatinous
Red-brown;"anchovy
paste"
Usuallygreen-
brown;mucinous
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MEDICAL THERAPY Albendazole :-is the drug of choice for medical
therapy. However, medical therapy alone for
echinococcal cysts has a less than 30%success rate.
The response has been shown to be higher inextrahepatic manifestations of the disease andwith the alveolar form caused by E.
multilocularis. Preoperative treatment with albendazole for at
least 3 months has been shown to reduce the
recurrence when cyst spillage, partial cystremoval or biliar ru ture has occurred.
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SURGICAL THERAPY
Scolecoidal Agents:-
not preferred now a days due to variouscomplications.
hypertonic saline can be used withprecautions.
many surgeons prefer a meticulous
surgical technique rather than overreliance on scolecoidal agents
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Open cyst evacuation
Open Cyst Evacuation:-. Cysts on the periphery of the liver are easily treatable byopen cyst evacuation..Anterior cysts are best treated through an abdominalapproach,. whereas cysts in segments VI and VII may be bestapproached through a lateral flank approach..Before entering the cyst, the field is lined with hypertonicsaline (20%) soaked gauze in the event of spillage ( Figure 2)..The cyst cavity is then opened, and the contents are
aspirated with a large suction device that can generate highnegative pressure..Once the contents are aspirated, the cyst can be opened
completely, and any remaining debris can be meticulouslycleared.
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continued
If the cyst is in connection with the bileducts as shown on preoperative ERCP,intra cavity scolecoidal agents should beavoided.
If a connection with the biliary tree isidentified, simple closure of the bile ductshould be performed using absorbablesutures, and the cyst cavity should be
filled with omentum. If the communication cannot be easilyclosed, external drainage with a closedsuction drain or internal drainage with acystojejunostomy may be warranted.
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continued
Laparoscopic cyst evacuation
Pericystectomy
Liver resection & transplantation