Flea Bytes: Hepatic Cysts

More common in women, 1.5:1 female to male ratio. 5% of people have cysts on autopsy and 5% of these are neoplastic. The majority of liver cysts (90%) are asymptomatic. Found incidentally on US or CT. Neoplastic cysts are mostly solitary. US imaging is most helpful and CT scan are used in specific cases. US helps determine content of the cysts. Certain cysts are responsive to estrogen.

Location in the liver does not help differentiate neoplastic from non-neoplastic.

Non-neoplastic cysts: wall is smooth, no septa, and no debris. Presence of these suggests the possibility of biliary cystadenoma or cystadenocarcinoma.

Liver tests are normal. In cases of congenital polycystic liver disease alkaline phosphatase maybe elevated.

Surgical removal and histologic sectioning is the only way to determine if neoplastic or not.

First must rule out Echinococcus – endemic worldwide and associated with rural areas with sheep. Test with ELIZA which is 90% sensitive. If surgery is not an option can consider aspiration. Mucin in cystic fluid is concerning for malignancy, but absence does not rule out malignancy. Also can check CEA and CA 19-9 in the aspirate, but inadequate NPV.

Monitor cysts that are 1-2cm, but if they grow to 2-5 consider, and definitely > 5 cm must consider surgery.

If all of the cyst tissue is removed, recurrence is unlikely, however if any part of the cyst wall is left behind recurrence can be up to 50%.
References:

Advances in Hepatology: Current Developments in the Treatment of Hepatitis and Hepatobiliary Disease: Managment of Heaptic Cysts – Jorge L Herrera
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2886389/

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Flea Bytes: Paracentesis and Bleeding Risk

AASLD Practice Guidelines:

Bleeding from paracentesis is relatively uncommon. The routine use of FFP or platelet transfusion is not recommended before paracentesis. You should avoid any engorged veins as most bleeding occurs from the venous circulation.

It may be reasonable to correct patients who have bled before with paracentesis, have hyperfibrinolysis (as they wouldn’t be able to clot effectively due to factor depletion), patients with evidence of overt bleeding from mucosa (epistaxis, vaginal bleeding, etc), or have history of bleeding at puncture sites (like IVs or blood draws).

Reference:

“Management of adult patients with ascites due to cirrhosis: an update.” Runyon BA. Hepatology. 2009;49(6):2087 

Flea Bytes: Differentiating Synthetic Dysfunction from DIC in Liver Disease

You can check factor VIII levels because they tend to be normal to increased in liver disease as it is not produced by the liver, but rather endothelial cells. In DIC all of the factors are consumed, so factor VIII levels will be low.

The other test that maybe helpful is checking a d-dimer. The d-dimer tends to be significantly increased in DIC due to profound fibrinolysis. However, d-dimer levels may also be elevated in liver disease, but usually only mildly elevated.

Flea Bytes: Child-Pugh Classification in Cirrhosis

2 scores really come to mind when discussing prognostication in cirrhosis: Child-Pugh Classification (Child-Turcotte-Pugh) or the Model for End Stage Liver Disease.

The Child-Pugh classification predicted operative mortality in the transection of the esophagus for the treatment of bleeding varices. A study was published by Dr Pugh in the British Journal of Surgery in 1973. The model they used to assess the severity of liver disease was based on the work of Child in 1964, but added the prothrombin time and eliminated the assessment of nutrition. See the table below for score calculation.

ChildPugh

CPMortality

The case series presented the outcomes of 38 patients who were admitted to King’s College Hospital in London from 1966-1972. The calculated the score for all the patients. The authors found a 29% mortality in Grade A, 28% mortality in Grade B, and found a whopping 88% mortality in Grade C. In this study only 4 patients with Grade C left the hospital and none survived to 6 months.