History and clinical examination
Patients with large liver cysts (> 5 cm) can develop symptoms such as abdominal pain, feeling of fullness, shortness of breath, leg swelling due to vena cava compression upon growth through stretching of the Glisson's capsule, rupture or pressure on neighboring organs.
The complaints can be very diverse and range from postprandial feeling of fullness with stomach compression to chronic capsular pain and hemorrhages up to symptoms due to bile duct or vascular compression by the tumor. If necessary, these complaints can be captured with the disease-specific Polycystic Liver Disease Questionnaire (PLD-Q) – a validated assessment tool.
Imaging procedures
Contrast-enhanced ultrasound represents the gold standard in the diagnosis of benign liver changes.
Computed tomography and MRI with specific contrast medium can further increase the sensitivity and specificity in the diagnosis of liver changes in conjunction with the ultrasound examination.
Simple hepatic cysts can already be diagnosed by a conventional ultrasound examination with a sensitivity and specificity of 90%:
- Ultrasound (if necessary CEUS, Contrast-Enhanced Ultrasound): Smoothly delimited, round-oval, homogeneously echo-free space-occupying lesion with dorsal sound enhancement, without internal structures or wall thickening. No calcifications, no internal reflexes, no wall nodules, no evidence of contrast uptake. Small septa (1–2 partitions) may occur. Sensitivity and specificity: approx. 90 %.
- CT: No internal structures, hypodense with fluid density (<20 HU), no contrast uptake.
- MRI: Low signal in T1, high signal in T2, without contrast uptake; decreasing intensity at higher b-values in diffusion imaging.
Differential diagnoses
Liver cysts with specific risk features in ultrasound (e.g. septa, fenestrations, calcifications, wall thickening or nodules, inhomogeneous internal structure or presence of daughter cysts) require further diagnostics using CT or MRI.
To be distinguished from the "uncomplicated" parenchymal cysts are other cystic formations:
- Caroli syndrome (congenital segmental cystic dilatation of the intrahepatic bile ducts)
- biliary hamartomas (Von Meyenburg complexes)
- congenital polycystic liver disease (PCLD)
- Post-traumatic or hemorrhagic cyst (internal echoes, layering phenomena)
Infectious cystic lesions
- Liver abscess (internal echoes, irregular wall)
- Echinococcus cysts (daughter cysts, wall calcifications)
cystically appearing malignant tumors such as e.g.
- Metastases of an ovarian carcinoma
- Cystadenocarcinoma of the liver (septa, nodules, contrast uptake)
