Management of Hepatic Cysts

Diagnostic Approach

Ultrasound is the first-line diagnostic modality for suspected hepatic cysts, with approximately 90% sensitivity and specificity for diagnosis 1, 4
Once a simple cyst is confirmed on ultrasound, no further imaging (CT or MRI) is indicated 1, 4
Hepatic cysts demonstrating complex features require further evaluation using MRI or CT 1, 5
MRI should be used to characterize hepatic cysts with worrisome features (100% consensus) 2, 5
The number of lesions (solitary vs. multiple) and architecture (simple vs. complex) are key elements in describing hepatic cysts 1, 5
Biliary hamartomas should be diagnosed by MRI with heavily T2-weighted sequences and MR cholangiography sequences 1, 2

No bloodwork is required for asymptomatic simple hepatic cysts, as these are benign developmental anomalies 4
Tumor markers (CEA and CA19-9) in blood or cyst fluid cannot be used to discriminate between hepatic cysts and mucinous cystic neoplasms 1, 2, 5, 6
TAG-72 in cyst fluid may help distinguish between simple hepatic cysts and mucinous cystic neoplasms, though evidence is limited 1, 5
If clinical features suggest infected hepatic cyst, obtain complete blood count and C-reactive protein to assess for leukocytosis and inflammation 4

It is not recommended to follow asymptomatic patients with simple hepatic cysts, biliary hamartomas, or peribiliary cysts (96% consensus) 1, 2, 5, 3
Simple hepatic cysts are benign lesions that typically follow an indolent course without significant changes in size over time 7, 6
If symptoms develop, ultrasound should be the first diagnostic modality used to assess size and look for complications or compression 2, 7, 3
Routine follow-up with imaging after aspiration sclerotherapy or surgical procedures is not recommended (92% consensus) 1, 2, 5, 6
Treatment success is defined by symptom relief, not by volume reduction of hepatic cysts 7, 6

Symptomatic simple hepatic cysts without biliary communication should be treated with the best locally available volume-reducing therapy (100% consensus) 1, 5, 6
Fluoroquinolones and third-generation cephalosporins are recommended as empirical first-line antibiotics (90% consensus) 1, 2, 5, 6
The recommended duration of antibiotic therapy is 4-6 weeks (100% consensus) 1, 2, 5, 6
Secondary prophylaxis for hepatic cyst infection is not recommended (92% consensus) 1, 2
Drainage of infected hepatic cysts may be pursued when: cysts >5-8 cm, fever persisting >48 hours despite antibiotics, pathogens unresponsive to antibiotic therapy, immunocompromise, hemodynamic instability or sepsis, or intracystic gas on imaging 1, 6

Abdominal ultrasound to screen for PLD should be offered to all patients diagnosed with ADPKD (100% consensus) 1, 2
Genetic testing should not be used to screen for PLD (100% consensus) 2
Referral to centers of expertise and counseling of patients with symptomatic PLD is recommended (100% consensus) 2
A combination of >1 major and >1 minor worrisome feature may be considered suspicious for MCNs (95% consensus) 1, 2
Surgical resection is the gold standard for suspected MCNs, and complete resection should be aimed for (100% consensus) 1, 2