Guideline sources The following summarized guidelines for the evaluation and management of hepatic cyst are prepared by our editorial team based on guidelines from the European Association for the Study of the Liver (EASL 2022) and the American College of Gastroenterology (ACG 2014). 1 2 Guidelines 1. Diagnostic investigations Diagnostic imaging: As per EASL 2022 guidelines, obtain ultrasound as the first-line imaging for the diagnosis of hepatic cysts. B Show 2 more As per ACG 2014 guidelines, obtain CT or MRI for further evaluation of a hepatic cyst identified on ultrasound with septations, fenestrations, calcifications, irregular walls, or daughter cysts. B Evaluation of mucinous cystic neoplasms: View a combination of 1 major and 1 minor feature as worrisome features for mucinous cystic neoplasms of the liver: major features: thick septation, nodularity https://web.pathway.md/diseases/recINRFlhaXp4fSIT 1/3 6/24/23, 12:40 PM Hepatic cyst Pathway minor features: upstream biliary dilatation, thin septations, internal hemorrhage, perfusional change, < 3 coexistent hepatic cysts. B Show 3 more Evaluation of cyst infection: diagnose definite hepatic cyst infection in the presence of neutrophil debris and/or microorganisms in cyst aspirate. B Show 2 more Evaluation of cyst hemorrhage: consider obtaining imaging to detect intracystic hemorrhage in patients with sudden and severe abdominal pain. C Show 2 more Evaluation of Caroli disease/syndrome: evaluate for congenital hepatic fibrosis to differentiate Caroli disease from Caroli syndrome in patients with multiple segmental cystic or saccular dilatations of bile ducts. B 2. Therapeutic procedures Drainage: As per EASL 2022 guidelines, offer the best locally available volume-reducing therapy for the treatment of symptomatic simple hepatic cysts without biliary communication. B As per ACG 2014 guidelines, do not perform aspiration of asymptomatic simple hepatic cysts. D 3. Surgical interventions Laparoscopic deroofing: consider performing laparoscopic deroofing rather than aspiration and sclerotherapy, dictated based on the availability of local expertise, in symptomatic patients with simple hepatic cysts. C 4. Specific circumstances Patients with cyst infection (antibiotic therapy): administer fluoroquinolones and third- generation cephalosporins for 4-6 weeks B as empirical first-line antibiotics in patients with hepatic cyst infection. B Patients with cyst infection (secondary prophylaxis): Do not administer secondary prophylaxis for hepatic cyst infection. D Insufficient evidence to recommend selective decontamination of the digestive tract to prevent hepatic cyst infection. I Patients with cyst hemorrhage: interrupt anticoagulants temporarily in patients with hepatic cyst hemorrhage B , and consider resuming 7-15 days after the onset of hepatic cyst hemorrhage. B https://web.pathway.md/diseases/recINRFlhaXp4fSIT 2/3 6/24/23, 12:40 PM Hepatic cyst Pathway Patients with cyst infection (drainage): Perform drainage of infected hepatic cysts in the presence of any of the following features: persistence of temperature > 38.5 C after 48 hours on empirical antibiotic therapy isolation of pathogens unresponsive to antibiotic therapy from a cyst aspirate severe immunocompromise CT or MRI detecting gas in a cyst large infected hepatic cysts. B Patients with mucinous cystic neoplasms: perform surgical resection, aiming for complete resection, as the gold standard for the management of patients with suspected mucinous cystic neoplasms. B Patients with biliary hamartomas: obtain MRI with heavily T2-weighted sequences and magnetic resonance cholangiography sequences for the diagnosis of biliary hamartomas. B Show 2 more Patients with Caroli disease/syndrome: Consider obtaining surveillance for cholangiocarcinoma with MRCP every 12 months after diagnosis in patients with Caroli disease and syndrome. C Consider referring patients with Caroli disease or syndrome with recurrent cholangitis for liver transplantation in the presence of bilobar involvement or monolobar involvement in combination with liver fibrosis or portal hypertension when the possibility of liver resection has been excluded. B 5. Follow-up and surveillance Serial imaging assessment: do not monitor asymptomatic patients with simple hepatic cysts or peribiliary cysts. D Show 2 more Expectant management: observe asymptomatic patients with simple hepatic cysts with expectant management. B References 1. European Association for the Study of the Live. EASL Clinical Practice Guidelines on the management of cystic liver diseases. EASL. 2022 Jun. Open 2. Marrero JA, Ahn J, Rajender Reddy K et al. ACG clinical guideline: the diagnosis and management of focal liver lesions. Am J Gastroenterol. 2014 Sep;109 9 1328 47. Open https://web.pathway.md/diseases/recINRFlhaXp4fSIT 3/3