Leg Swelling and Mildly Deranged Liver Tests: An Unusual Presentation of a Usual Diagnosis

Abstract

Question: A 72-year-old woman presented to the hospital with progressively worsening left lower extremity swelling and pain of 1 weeks’ duration. She also reported vague right upper abdominal discomfort, but did not complain of nausea, vomiting, shortness of breath, chest pain, fever, or jaundice. Her past history was significant for hypertension and Meniere disease. She had had no prior surgeries and was a lifetime nonsmoker. Her current medications were hydrochlorothiazide-triamtrene, aspirin, calcium-vitamin D, and a multivitamin. On examination, she had 2+ pitting pedal edema with mild tenderness of left lower extremity. Abdomen was soft and nontender with no palpable organomegaly or mass. The rest of the physical examination was unremarkable. Laboratory tests showed: hemoglobin, 11.8 g/dL; platelets, 277,000/μL; International Normalized Ratio, 1.3; total bilirubin, 1.4 mg/dL; alkaline phosphatase, 279 IU/L; alanine aminotransferase, 39 IU/L; and aspartate aminotransferase, 38 IU/L. Lower extremity ultrasound duplex examination was performed and showed deep venous thrombosis of left femoral vein. CT of the abdomen with oral and intravenous contrast was subsequently obtained (coronal sections; Figure A, B). What is the diagnosis? See the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI. CT of the abdomen with contrast showed multiple simple liver cysts (SLCs) with a large cyst (12.2 × 11.4 × 13.1 cm) in segment IV of liver causing extrinsic inferior vena cava (IVC) compression (black arrow in Figure C) and extensive venous thrombosis extending from the left ileofemoral veins to the IVC (white arrows in Figure D). After initiation of therapeutic anticoagulation with subcutaneous weight-based enoxaparin, the patient underwent percutaneous catheter-guided thrombolysis of IVC and ileofemoral thrombus. Open surgical fenestration of large liver cyst was performed the next day. Pathologic examination of the cyst wall showed cuboidal epithelium with no features of biliary cystadenoma. The patient was discharged on post-operative day 5 on oral warfarin. SLC are the most common nonparasitic cystic lesions of liver estimated to occur in approximately 5% of the population.1Kelly K. Weber S.M. Cystic diseases of the liver and bile ducts.J Gastrointest Surg. 2014; 18: 627-634Crossref PubMed Scopus (10) Google Scholar They are usually asymptomatic, detected incidentally, and do not carry malignant potential. Differential diagnoses of SLC include parasitic cyst, hepatic abscess, and neoplastic cyst. Large cysts can become symptomatic owing to hepatomegaly, mass effect on adjacent organs, or complications like infection, rupture, biliary obstruction, and intracystic hemorrhage. Rarely, a liver cyst can cause extrinsic compression of IVC, which predisposes to thrombus formation by causing venous stasis, as in our patient.2England R.A. Wells I.P. Gutteridge C.M. Benign external compression of the inferior vena cava associated with thrombus formation.Br J Radiol. 2005; 78: 553-557Crossref PubMed Scopus (20) Google Scholar SLCs do not require treatment unless symptomatic. Treatment options include aspiration–sclerotherapy, surgical fenestration, or hepatic resection.3Koperna T. Vogl S. Satzinger U. et al.Nonparasitic cysts of the liver: results and options of surgical treatment.World J Surg. 1997; 21: 850Crossref PubMed Scopus (76) Google Scholar Aspiration–sclerotherapy, although noninvasive, is associated with higher recurrence and complication rates than laparoscopic fenestration, and may be reserved for patients who are poor candidates for surgery and general anesthesia.3Koperna T. Vogl S. Satzinger U. et al.Nonparasitic cysts of the liver: results and options of surgical treatment.World J Surg. 1997; 21: 850Crossref PubMed Scopus (76) Google Scholar