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C.P.C. RUQ Cystic Mass and Fever

C.P.C. RUQ Cystic Mass and Fever. By William E. Stevens M.D. CPC Case Highlights. Young, Latin-American, Male, Homosexual 2 weeks fever, chills, night-sweats 1 week RUQ pain 5-10 pound weight loss Exam: temp 102.5; RUQ tenderness

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C.P.C. RUQ Cystic Mass and Fever

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  1. C.P.C.RUQ Cystic Mass and Fever By William E. Stevens M.D.

  2. CPC Case Highlights • Young, Latin-American, Male, Homosexual • 2 weeks fever, chills, night-sweats • 1 week RUQ pain • 5-10 pound weight loss • Exam: temp 102.5; RUQ tenderness • Labs: normal WBC 5.7, mildly abnormal LFT’s (hepatitis risk factors); elevated total protein to albumin ratio; elevated CRP and ESR • CT scan: 8.5 cm cystic / solid mass in RUQ, heterogeneous, non-enhancing walls, IVC thrombosis, ?pushing or invading into liver

  3. RUQ Cystic Mass and FeverDifferential Considerations • Primary infection • Bacterial abscess • Amebic abscess • Echinococcosis • Malignancy • Liver • Adrenal • Renal • Pancreatic • Lymphoma, other • Benign Mass with secondary infection • Hepatic cyst with infection or focal cholangitis • Pancreatic pseudocyst with infection • Choledochal cyst • Renal, adrenal, mesenteric and duplication cysts • Multiple problems • Chronic viral hepatitis with a cystic mass • HIV infection with a cystic mass

  4. Bacterial Abscess • Pyogenic liver abscess • Symptoms: Fever 90%; pain 55%; weight loss 40%; jaundice 50% • Usually multiple 50%; right lobe involved 60% • Etiology: biliary 55%, cryptogenic 15%, other: appendicitis, diverticulitis, etc. • Other abdominal abscesses • Diverticular abscess • Perinephric abscess • Cholecystitis with abscess • Perforated ulcer with abscess • Perforated appendix with abscess • Treatment • Drainage, antibiotics, surgery

  5. Amebic Abscess • Entamoeba histolytica • Fecal-oral transmission • 5-10% in U.S. are asymptomatic cyst passers • Pathophysiology • Ingested cyst is resistant to gastric acid • Ameba becomes active in small intestine and passes into colon • Ameba invade colonic mucosa causing acute and chronic colitis • Ameba invade into mesenteric veins thus reaching the liver • Cystic necrosis of hepatocytes

  6. Entamoeba histolytica

  7. Amebic AbscessClinical Presentation • More common in young, male, Latin-American, HIV+ • 60% have history of travel to endemic country • Duration of illness is usually < 2 weeks • 20% have history of dysentery, 10% have dysentery • 90% have RUQ pain or epigastric, chest or right shoulder pain • 75% have fever • Right hepatic lobe involved in 80-95% • LFT’s mildly, nonspecifically elevated; < 10% jaundice • Leukocytosis and anemia are common

  8. Amebic AbscessDiagnosis • Ultrasound and CT • Usually solitary, round, peripheral, right lobe • Through transmission, hypoechogenicity • Wall usually enhances with IV contrast • Occasionally will have nodular border or internal septations • Amebic Serology • ELISA has > 90% sensitivity • Can’t differentiate past from current infection • Liver Aspiration • Not usually necessary • Pus is reddish brown “anchovy paste”, usually sterile • Aspirate if diagnosis is uncertain, large abscess, “impending rupture”, left lobe involvement, non-response to treatment

  9. Amebic Abscess • Complications • Pleuropulmonary rupture • Hepatic rupture, amebic peritonitis • Usually sudden severe abdominal pain • Occasionally slow leak with walled off abscess • Rupture into pericardium, pericarditis • Hemobilia • Rupture into bowel • Treatment • Aspiration if needed • Flagyl 750 mg TID for 10 days • Iodoquinol 650 mg TID for 20 days

  10. Echinococcosis • Echinococcus granulosa and multilocularis • Small 3-6 mm tape worms • Definitive host: Dog, others • Ingests infected viscera • Passes eggs into stool • Intermediate host: Human, sheep, cattle, others • Ingests food contaminated with egg laden feces • Egg is digested in small bowel releasing embryo • Embryo invades mucosa entering mesenteric veins • Embryo become trapped in liver (70%), lung (20%), spleen, kidney, bone, CNS, etc. • Endemic in areas where dogs are used to help raise livestock

  11. Echinococcus granulosa

  12. Echinococcus Life Cycle

  13. Echinococcosis • Symptoms occur years after acute infection • Cyst produces mass effect enlarging ~1 cm/year • RUQ pain • CBD compression, obstructive jaundice • Portal vein compression, portal hypertension • Cyst may rupture; contents are highly antigenic • Anaphylactic shock • Free rupture into peritoneum • Rupture into biliary tract: obstruction, pancreatitis, cholangitis • Rupture into pleura, pericardium, colon, duodenum, kidney • Cysts may become secondarily infected • Labs • Mild leukocytosis, 40% have eosinophilia • ELISA IgG is 97% sensitive • Radiology • Cystic mass; walls occasionally calcified; rim often enhances with IV contrast • Daughter cysts

  14. EchinococcosisCT Appearance

  15. Echinococcosis • Diagnosis • Typical radiological appearance • MRI provides more data than CT • ELISA IgG is 97% sensitive • Aspiration is relatively contraindicated due to risk of cyst leakage and anaphylaxis • Treatment • Surgery: remove all cysts if possible • Avoid spillage of cyst contents • Large cysts may be injected with hypertonic saline and aspirated in OR before removal • 10-30% recur • Albendazole 400 mg BID for 28 days • Non-surgical injection and aspiration only in unresectable cysts or patients who are non-operable

  16. Neoplastic Hepatic Cysts • Any primary or metastatic cancer can appear cystic due to central necrosis or hemorrhage • Choriocarcinoma, ovarian carcinoma, sarcoma, islet cell tumors, lymphoma • Biliary cystadenoma / cystadenocarcinoma • Most common in women over age 40 • Cystic, septated masses, irregular wall margins, more often in right lobe • Mucous secreting cuboidal epithelium with ovarian type stroma • Walls and septations are more vascular by pulse doppler • Cavernous hemangioma • Most common hepatic tumor; usually asymptomatic • Men = women, but estrogens enhance growth • Often appear cystic, occasionally pedunculated • Rarely will rupture, usually due to trauma • Teratoma • Mesenchymal hamartoma

  17. Benign Noninfectious Hepatic Cysts • Solitary • Simple Cysts • 3.6% population; F:M = 4:1 • Almost always asymptomatic • Usually <5 cm, usually right lobe • Thin walls; more than one cyst may be present • Post-traumatic • Post-hepatic infarction • Rarely can cause pain, hemorrhage, become infected • Polycystic • Autosomal dominant adult polycystic kidney disease • Autosomal recessive polycystic kidney disease and Congenital hepatic fibrosis • Caroli’s Disease • Von Meyenburg complexes • Other congenital syndromes • Peliosis hepatis

  18. Other RUQ Cystic Masses • Pancreatic Cysts • Simple pancreatic cysts • Pancreatic pseudocysts • Almost always have a history of pancreatitis or trauma • Complicates 10% cases of acute pancreatitis • More common in ETOH pancreatitis • Usually lack septae; may be loculated; may have calcium; cysts may travel to unexpected areas • Cyst fluid has a very high amylase • Pancreatic cystic neoplasm • 80% are women; usually > 55 years old; usually involve body and tail pancreas • Mucinous cystic neoplasm (45%); intraductal papillary mucinous neoplasm (30%); serous cyst adenoma (15%) • EUS is best diagnostic test • Choledochal Cysts • Congenital cystic dilation of the biliiary tract • 60% present before age 10 • Recurrent RUQ pain, fever, abnormal LFT’s

  19. More RUQ Cystic Masses • Adrenal Cysts • 15% of adrenal cysts are malignant • Adrenal cortical carcinoma and adenoma • Pheochromocytoma • Cystic lymphangioma and neuroblastoma • 85% are benign • Hemorrhagic adrenal pseudocyst • Hydatid cyst • Renal Cysts • Solitary cysts and Polycystic kidney disease • Renal cell carcinoma • male > female; usually age > 50; increased risk IVC thrombosis; 60% have hematuria • Mesenteric Cysts • Very rare; 3% are malignant • 60% have localized pain, occasionally fever, chills • Duplication Cysts • Rare; congenital; attached to gut; lined by G.I. mucosa

  20. HIV Related Liver Diseases • Hepatitis B and C • Increased incidence in HIV+ patients • When compared to HIV negative patients: • Higher viral load • Lower ALT • More severe histology • Less responsive to medical therapy • Mortality from liver disease much higher • Increased risk of Hepatoma and Lymphoma with chronic hepatitis • Peliosis hepatis • Fever, RUQ pain, hepatic cystic masses usually < 3cm in size • Blood filled cavities • Related to Bartonella infection; CD-4 count < 200 • Amebic abscess • 60% of patients without a travel history are immunosuppresed or HIV+ • Many others: fungal abscess, Kaposi’s sarcoma, Lymphoma

  21. RUQ Cystic Mass and FeverDiagnostic Studies • Recommend: • Send serologies for ameba and Echinococcus • Send serologies for HIV, Hepatitis B and C • Aspirate and Biopsy cystic mass if ameba and Echinococcus serologies are negative

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