Hepatic Cyst

A simple hepatic cyst is a benign fluid filled biliary developmental lesion that does not communicate with the biliary tree.

Most are discovered incidentally and remain asymptomatic.

The important clinical task is distinguishing a true simple cyst from hydatid disease, liver abscess, biliary cystic neoplasm, cystic metastasis or other complex hepatic lesions.

Size alone is not an indication for intervention if the patient is asymptomatic and the lesion has unequivocally benign characteristics.

Most patients have no symptoms.

Large cysts may produce:

• Right upper quadrant pressure
• Early satiety
• Abdominal distension
• Local discomfort

Complications are uncommon but include haemorrhage, infection, rupture and compression of the biliary tree or major vascular structures.

Sudden severe pain can result from intracystic haemorrhage or rupture.

Ultrasound: usually sufficient to confirm a simple uncomplicated hepatic cyst.

A cyst with septations, mural nodules, irregular thickening, daughter cysts, debris or another atypical feature requires further characterisation rather than being labelled a simple cyst.

CT or MRI is appropriate for complex, symptomatic or diagnostically uncertain lesions.

An asymptomatic unequivocally simple hepatic cyst requires no treatment.

Routine serial imaging is unnecessary once the diagnosis is secure and no concerning structural features exist.

Treat symptomatic cysts only after confirming that the cyst is actually responsible for the symptoms.

Percutaneous treatment

Simple needle aspiration alone is inadequate definitive treatment because the secretory epithelial lining remains and the cyst usually refills.

Percutaneous aspiration followed by sclerotherapy is an effective minimally invasive option for selected symptomatic simple cysts without biliary communication. Contemporary pooled data show symptom improvement in the large majority of treated patients.

Surgery

Laparoscopic fenestration or deroofing is appropriate for a large symptomatic superficial cyst, recurrent cyst after percutaneous treatment or when durable wide drainage into the peritoneal cavity is preferred.

Excise a substantial portion of the extrahepatic cyst wall rather than simply creating a tiny opening that can seal and recur.

Formal hepatic resection is rarely required for a true simple cyst. Consider it when cyst anatomy is complex, diagnosis remains uncertain or the lesion occupies a difficult central location where simple fenestration cannot safely provide definitive treatment.

Do not fenestrate a suspected biliary cystic neoplasm or hydatid cyst as though it were a simple hepatic cyst.