ACG recommends full patient workup, evaluation to differentiate focal liver lesions

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Key takeaways:

  • For lesions of unknown etiology, the ACG recommends multiphasic contrast-enhanced imaging.
  • The ACG recommends discontinuing oral contraceptives or hormone-impregnated intrauterine devices for hepatic adenoma.

In a new clinical practice guideline, the ACG has provided evidence-based recommendations for the diagnosis and management of the most common focal liver lesions among individuals without known liver disease.

“With the continued dramatic rise in the widespread role of imaging in diagnosis and management of patients, there is a resultant rise in detection of asymptomatic incidental liver lesions,” Catherine Frenette, MD, of Family Health Centers of San Diego, and colleagues wrote in the American Journal of Gastroenterology. “It is critical to understand appropriate management of incidentally detected benign focal liver lesions because they have differing clinical implications from malignant lesions such as hepatocellular carcinoma, intrahepatic cholangiocarcinoma and metastatic disease.”


Using the Problem, Intervention, Comparison and Outcome format, the ACG updated the existing clinical guidelines for diagnosis and management of focal liver lesions by developing key questions, which guided a subsequent literature search and development of 18 recommendation statements and additional key concepts.

Further, the Grading of Recommendations, Assessment, Development and Evaluation process was used to evaluate the quality of evidence for each recommendation statement developed for the diagnosis and management of hepatic adenoma, focal nodular hyperplasia, hemangioma, simple hepatic cysts, polycystic liver disease and hydatid/echinococcal cysts — the most common focal liver lesions.

Highlights from the clinical guideline include:

  • The ACG recommends multiphasic contrast-enhanced imaging, preferably MRI or CT performed with late arterial, portal venous and delayed phases, among patients with focal liver lesions of unknown etiology.
  • The ACG recommends discontinuation of oral contraceptives or hormone-impregnated intrauterine devices in those with hepatic adenomas.
  • Among women with hepatic adenomas smaller than 5 cm, the ACG recommends discontinuation of exogenous hormones. They should also undergo surveillance with contrast-enhanced imaging modalities every 6 months for 2 years and annually thereafter.
  • Among patients with suspected hemangioma and cirrhosis or chronic hepatitis B who meet the criteria for HCC surveillance, the ACG recommends continued imaging surveillance every 3 to 6 months for at least 1 year.
  • Among those with asymptomatic simple hepatic cysts, the ACG recommends expectant management without routine surveillance or intervention, regardless of cyst size. For patients with specific high-risk features identified on ultrasound, the ACG recommends further investigation with CT or MRI.
  • The ACG recommends somatostatin analogs for patients with polycystic liver disease with numerous small- to medium-sized cysts not amenable to surgical resection, cyst fenestration or aspiration sclerotherapy.
  • Provided there are no surgical contraindications, the ACG suggests surgical management for patients with complicated hydatid cysts. If surgery is not an option, the ACG suggests percutaneous treatment with puncture, aspiration, injection of scolicidal agent and reaspiration with adjunct antihelminthic therapy.

“Focal liver lesions continue to be a frequent source of concern for providers and patients alike, and detection will likely continue to rise in incidence as an increasing volume of radiographic imaging studies are being performed,” Frenette and colleagues wrote. “Many focal liver lesions are benign, but it is important to understand indications for further workup, including multidisciplinary discussion, biopsy and need for surveillance imaging to ensure that a malignancy is not missed.”

They continued: “The clinical history, physical examination, underlying comorbidities and laboratory workup are an important part of the evaluation of these patients, which, when combined with improved diagnostic imaging, can frequently lead to a diagnosis without the need for biopsy.”

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