Baptist Health-University of Arkansas for Medical Sciences North Little Rock, AR
Imtiaz Ahmed, MD1, Hayder Alamily, MD2, Sana Rabeeah, MD3, Ban Mashadani, MD1, Mazin Al-Dujaili, MD4, Mushfiqur Siddique, MD5, Abdulrahman Khaldoon. Hamid, MD6, Omer Najem, MD7 1Baptist Health-University of Arkansas for Medical Sciences, North Little Rock, AR; 2University of Colorado Anschutz Medical Campus, Denver, CO; 3The University of Toledo, Toledo, OH; 4St. John’s Episcopal Hospital, Far Rockaway, NY; 5Jamaica Hospital Medical Center, Jamaica, NY; 6Jamil Tutanji Hospital, Amman, 'Amman, Jordan; 7Department of internal medicine, Trinity Health Oakland, Pontiac, MI Introduction: Hepatic cysts are commonly incidental findings, often benign and asymptomatic. However, large or hemorrhagic cysts may mimic malignancy or subcapsular hematoma, presenting significant diagnostic and management challenges. We present a rare case of a massive hepatic cyst with spontaneous hemorrhage, elevated tumor markers, and compressive symptoms initially concerning for malignancy.
Case Description/
Methods: An 80-year-old woman with hypertension presented with right upper quadrant pain, weight loss, and hypoxia. Imaging revealed a complex 18.7 cm right hepatic cyst with internal blood products and associated pleural effusion. Tumor markers showed elevated CA 19-9 (1,743), with normal AFP and CEA. Initial aspiration was negative for malignancy. On readmission, worsening symptoms and enlarging cyst prompted CT-guided drainage of over 2 liters of hemorrhagic fluid, again negative for infection or malignancy. Right-sided thoracentesis yielded exudative fluid without evidence of malignancy. During hospitalization, the patient developed left leg DVT and underwent IVC filter placement due to contraindication to anticoagulation. She was discharged with a hepatic drain in place. Follow-up imaging showed interval cyst reduction (to ~14 cm). CA 19-9 decreased to 32.7. Surgical consultation recommended laparoscopic fenestration if symptoms persisted. Discussion: This case highlights a rare presentation of a hemorrhagic hepatic cyst simulating a subcapsular hematoma or malignancy. Elevated CA 19-9 and complex imaging features initially raised concern for neoplasm. However, comprehensive evaluation and serial fluid analyses confirmed benign pathology. The case underscores the importance of integrating imaging, tumor markers, and fluid cytology in hepatic cyst evaluation. Additionally, complications such as DVT due to delayed anticoagulation require multidisciplinary coordination. Massive hemorrhagic hepatic cysts can mimic neoplastic or vascular pathology. Early diagnostic imaging, cautious fluid analysis, and appropriate follow-up are crucial for accurate diagnosis and symptom relief. This case adds to the limited literature on large hepatic cysts with hemorrhagic transformation.
Figure: Axial and coronal contrast-enhanced CT images reveal a large, well-defined complex cystic lesion in the right hepatic lobe with internal high-attenuation components, consistent with hemorrhage. The lesion demonstrates mass effect on adjacent liver parenchyma and surrounding structures, initially raising concern for a subcapsular hematoma. Imaging confirmed a hemorrhagic hepatic cyst.
Figure: Chest X-ray shows elevation of the right hemidiaphragm with obscuration of the right lung base due to mass effect from the underlying hepatic lesion. Abdominal ultrasound reveals a large complex fluid collection within the right lobe of the liver, consistent with a hemorrhagic hepatic cyst.
Disclosures: Imtiaz Ahmed indicated no relevant financial relationships. Hayder Alamily indicated no relevant financial relationships. Sana Rabeeah indicated no relevant financial relationships. Ban Mashadani indicated no relevant financial relationships. Mazin Al-Dujaili indicated no relevant financial relationships. Mushfiqur Siddique indicated no relevant financial relationships. Abdulrahman Hamid indicated no relevant financial relationships. Omer Najem indicated no relevant financial relationships.
Imtiaz Ahmed, MD1, Hayder Alamily, MD2, Sana Rabeeah, MD3, Ban Mashadani, MD1, Mazin Al-Dujaili, MD4, Mushfiqur Siddique, MD5, Abdulrahman Khaldoon. Hamid, MD6, Omer Najem, MD7. P4004 - Hemorrhagic Hepatic Cyst Mimicking Subcapsular Hematoma: A Rare and Complex Diagnostic Challenge, ACG 2025 Annual Scientific Meeting Abstracts. Phoenix, AZ: American College of Gastroenterology.
