Using temporal changes in MR images to determine treatment options for complex liver cysts

The prevalence of hepatic cyst (HC) ranges from 2.5 to 4.7%. Among them, HCs with with symptoms occur in 15%. Extrahepatic rupture of HCs with hemorrhagic shock and death may occur. Early detection of intracystic hemorrhage is necessary to prevent lifethreatening complications. In this case, a 77-year-old woman underwent regular checkups. Her ultrasound (US) showed multiple hepatic cysts (HCs). The largest HC was 80 mm in diameter and located in segment 8 of the right lobe. Her prognostic nutritional index (PNI) was 41.7, indicating high surgical morbidity and mortality after surgery. Multidetector computed tomography (MDCT) and magnetic resonance imaging (MRI) were added to identify intra- and extra-cystic anatomy. Compared to MDCT, MRI was able to identify intra-cystic heterogeneous low and high intensity. These findings were interpreted to indicate acute to chronic intra-cystic hemorrhage. As a complication of the rupture and death, an anterior segmentectomy with segmentectomy with cholecystectomy was planned and performed. Her postoperative course was uneventful and she was discharged on day 16. The life-threatening complex HCs include intra-cystic hemorrhage, rupture, hemorrhagic shock and death. To prevent these, we would like to emphasize that MRI appears to be superior to US or CT in providing accurate information on the time course of intra-cystic hemorrhage from hemoglobin to hemosiderin changes to guide urgent surgical intervention of hepatectomy to prevent HC rupture and prevent HC rupture and death.