Initial management of a pyogenic liver may include all of the following EXCEPT?
Pyogenic abscesses are the most common liver abscesses seen in the United States. Though traditionally a result of intraabdominal infections such as appendicitis and diverticulitis, earlier diagnosis of these conditions in patients has reduced prevalence of these conditions as causes for pyogenic liver abscess. Other etiologies include impaired biliary drainage, subacute bacterial endocarditis, dental work, infected indwelling catheters, or direct extension from abscesses related to inflammatory bowel disease. Pyogenic liver abscesses are most commonly seen in the right lobe of the liver, and Escherichia coli is the most commonly isolated pathogen. Approximately 40% of abscesses are polymicrobial, while 20% of culture negative. Treatment of pyogenic liver abscesses include correction of the underlying cause and intravenous antibiotics for at least 8 weeks, which is effective in approximately 80 to 90% of patients. Empiric antibiotic coverage should include gramnegative and anaerobic organisms, with percutaneous aspiration and culture used to tailor long-term antibiotic therapy. Placement of a percutaneous drainage catheter may be considered, though it is often ineffective due to the viscous nature of the collection. Surgical drainage or resection is reserved for patients who fail nonoperative management.
The most common benign hepatic lesion is the:
While hemangiomas are the most common solid benign masses found in the liver, the simple hepatic cyst is still the most common overall. Simple cysts have a prevalence of approximately 2.8 to 3.6%, and are more common in women by a ratio of 4:1. Cysts are generally found incidentally during abdominal imaging, and small, asymptomatic cysts may be managed conservatively. Large cysts may begin to cause abdominal pain, epigastric fullness, and early satiety. These patients may be treated with percutaneous cyst aspiration and sclerotherapy which is effective in approximately 90% of patients. For those who fail percutaneous treatment, or where percutaneous treatment is not available, surgical cyst fenestration may be considered. If surgical fenestration is performed, the cyst wall should be sent for pathologic analysis to exclude carcinoma.
Which of the following liver lesions carry a significant risk of spontaneous rupture?
Hemangiomas are congenital vascular lesions that may range in size from less than 1 to 25 em or greater. They are predominantly found in women, and are generally asymptomatic. Large lesions may result in discomfort from compression of nearby organs. Though hemangiomas are at risk for bleeding if they are biopsied, spontaneous rupture is rare. Adenomas, on the other hand, carry a significant risk for spontaneous rupture with intraperitoneal bleeding. For this reason, along with their potential for malignant degeneration, it is generally recommended that hepatic adenomas be resected once discovered.
A patient presents with results from a contrast-enhanced CT scan that describe a well-circumscribed lesion that demonstrates homogenous enhancement during arterial phase, isodensity on the venous phase, and a central scar. In general, what would be the recommended treatment?
On contrast -enhanced imaging, a focal nodular hyperplasia (FNH) can be recognized as a well-circumscribed mass that demonstrates enhancement on the arterial phase and isodensity on the venous phase. FNH also demonstrates a characteristic central scar. FNH are solid benign lesions, are similar to adenomas, and are more common in women of childbearing age. Unlike adenomas, however, they are not prone to malignant degeneration or spontaneous rupture. For this reason, asymptomatic FNHs may be managed conservatively unless adenoma or HCC cannot be definitively excluded. Gadolinium-enhanced MRI may allow better visualization of the fibrous septa extending from the FNH's central scar. While FNH and adenomas may appear similar on CT or standard MRI, new MRI contrast agents, such as gadobenate dimeglumine (MultiHance), allow superior discrimination between these two lesions.
What is the annual conversion rate to HCC for patients with cirrhosis?
HCC is the fifth most common malignancy worldwide, and its risk factors include viral hepatitis, alcoholic cirrhosis, hemochromatosis, and NASH. Cirrhosis is present in 70 to 90% of patients who develop HCC, and the annual conversion rate from cirrhosis is 2 to 6%.
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