University of Oklahoma Health Sciences Center Oklahoma City, OK
Introduction: Hepatic cysts are the most common benign lesions in the liver. Overall incidence among the population is about 5%, being more common in women. Therapeutic interventions are reserved for acutely symptomatic patients with life threatening complications. Herein, we highlight a unique case of a patient with a massive right hepatic cyst, drained under the guidance of an endoscopic ultrasound (EUS), along with a literature review of its applications in Endo-Hepatology.
Case Description/Methods: A 76-year-old male with a history of benign liver cyst, presented with severe right upper quadrant abdominal pain associated with nausea and vomiting. On physical examination, he had a markedly distended, diffusely tender abdomen, with palpable hepatomegaly. Initial blood work revealed a Hb of 6.7 g/dL (known baseline Hb was 9 g/dL). Compared to previous imaging from 2014 (Figure A), CT abdomen revealed significant enlargement of a known right hepatic cyst (largest dimension: 24.2 X 16 X 25.6 cm) (Figure B). Volume resuscitation with blood transfusions was done. An EUS guided drainage of the cyst using a Lumen-Apposing Metal Stent (LAMS) was performed. After locating an appropriate avascular window, the cyst was successfully traversed, sterile contrast was used to delineate the lesion, followed by deployment of the LAMS. A total of 2.8 liters of dark, reddish-brown fluid was drained, with an additional 1.1 liter suctioned out through a nasogastric (NG) tube over the next 24 hours. Following the procedure, the patient remained hemodynamically stable with significant improvement symptomatically.
Discussion: Diagnostic imaging is essential in delineating the characteristics of liver cysts to determine the appropriate intervention. Decision regarding the choice of intervention should be individualized for each patient. Therapeutic interventions for liver cysts are predominantly performed through a percutaneous (PC) route, with EUS being deemed as a safe alternative when PC intervention is not favorable. The efficacy and recurrence rates of liver cysts after drainage with EUS versus PC drainage with sclerotherapy have been compared previously, with EUS guided drainage being recognized traditionally as a safe approach in drainage of left/caudate lobe hepatic cysts, and PC drainage being preferred for right lobe/hepatic dome cysts. EUS also aids in detection of smaller, focal liver lesions not apparent on gross imaging, elastography, biopsies, portosystemic pressure gradient monitoring and thermal ablative therapy.
