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A Case Report of Incidental Hepatic Cysts Found on Ultrasound Imaging

Implications for the Anesthesiologist

Hasan, Aysha MD; Alrayashi, Walid MD; Waisel, David MD; Boretsky, Karen MD

doi: 10.1213/XAA.0000000000000627
Case Reports: Case Report
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Point-of-care ultrasound imaging is increasingly used by anesthesiologists to facilitate rapid clinical diagnosis and treatment in the perioperative period. With its growing popularity, inevitably, unfamiliar structures will be observed. We present a case of cystic liver lesions in a healthy model during a point-of-care workshop. We address the clinical, ethical, and legal implications of incidental findings in anesthesiology. We offer recommendations and an algorithmic approach to these occurrences.

From the Department of Anesthesiology Perioperative and Pain Medicine, Boston Children’s Hospital, Boston, Massachusetts.

Accepted for publication July 26, 2017.

Funding: None.

The authors declare no conflicts of interest.

Address correspondence to Aysha Hasan, MD, Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children’s Hospital, 300 Longwood Ave, Boston, MA 02215. Address e-mail to AyshaHasan@gmail.com.

While anesthesiologists have used bedside ultrasound since 1978,1 new clinical applications are being embraced. Point-of-care (POC) ultrasonography is becoming an effective tool for anesthesiologists to facilitate rapid diagnosis and treatment of patients in the perioperative period. Examples of its uses include determining gastric volume, diagnosing hemodynamic instability, and confirming endotracheal tube placement.2,3 Increased use of ultrasound imaging will likely lead to more incidental findings. We present a case of liver cysts discovered in an otherwise healthy model during a training workshop. The primary objective of this case report is to provide a reasonable approach toward management of the discovery of incidental findings on POC ultrasound. Secondary goals include identification of practice limitations and a brief review of the legal issues associated with incidental findings. Written consent was obtained from the patient to publish this case report.

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CASE DESCRIPTION

We present a case of a healthy, 52-year-old, 50-kg woman who volunteered to be a model for abdominal scanning at a POC ultrasound workshop. While she was in the supine position, we used a 2- to 4-MHz curvilinear transducer (9C2; Analogic Inc, Peabody, MA) in a right longitudinal intercostal oblique position to show the Morrison pouch, which revealed a single small cystic structure (Figure 1). Sliding the longitudinally positioned transducer anterior to a standard subcostal view used for gallbladder imaging, we found additional fluid-filled cysts, which were thin-walled lesions without septations or debris (Figure 1).

Figure 1

Figure 1

The model, who was unaware of the liver cysts, was told that she had several cystic-looking structures in her liver. She denied symptoms of abdominal fullness, jaundice, nausea, vomiting, or abdominal pain. She was not a smoker and consumed wine occasionally. She led an active lifestyle running 3–5 miles several times per week. The model was advised to follow up with her primary care provider for a more formal evaluation with a designated specialist. Completed evaluation revealed that the structures seen were benign cysts needing no further workup.

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DISCUSSION

Increasing use of bedside portable ultrasound imaging for diagnostic purposes is facilitating decision making and allowing for specific, targeted therapy in a timely fashion. As with any new technology, anesthesiologists should understand the potential pitfalls that can arise from a lack of specific training.2,3 Images that are unfamiliar can be disconcerting, which may lead to misinterpretations, incorrect assessments, and poor clinical management. POC-specific training programs will ultimately expand the training and scope of practice to include recognition of common pathology versus variations such as liver cysts, foramen ovale, air embolism, pneumothorax, and pleural fluid. Curricula should include a plan for initiating a stepwise approach upon discovery of incidental findings.3

Literature related to incidental findings originates from radiology, surgery, and emergency medicine. The anesthesiologist’s role in discovery of incidental findings is poorly considered. We suggest an algorithmic approach presented in Figure 2. The preoperative discussion of the risks and benefits with the planned use of POC ultrasonography should anticipate the potential for incidental findings. During a POC examination, the anesthesiologist discovering an incidental finding has 1 of 2 routes to pursue. Knowledge gaps in determining acute (defined as life-threatening or high-risk finding leading to an adverse event to the patient if not treated immediately) versus nonacute (defined as a low-risk finding that can be followed up at a reasonable time without causing harm to the patient) can be mitigated with a secondary opinion from a more expert clinician. Confronted with an acute finding, the anesthesiologist should weigh the risks and benefits of proceeding with the original procedure. In a nonacute finding, the anesthesiologist can pursue different routes of management based on the patient population they are managing. For pediatric patients, incidental discoveries can be discussed with the parent or guardian while the child is anesthetized. After obtaining appropriate consent, the health care team can proceed with further workup before or after the originally scheduled procedure based on the acuity of the finding. In the adult population, a nonacute incidental finding typically would require the practitioners to discuss the options with the patient after they are awake and able to consent for further care.

Figure 2

Figure 2

Incidental ultrasonography findings of focal liver lesions are nearly always benign and are most commonly focal fatty sparing liver lesions or simple hepatic cysts.4 An analogous forum in which incidental lesions can be found is magnetic resonance imaging of cardiovascular lesions. A published review of cardiac magnetic resonance imaging demonstrated a 5.3% (356/4165) incidence of extracardiac incidental findings of which 8.1% (29/356) were hepatic cysts. While this study showed a low prevalence of incidental findings, 23.7% of the incidental findings revealed a new diagnosis requiring further workup. Awareness of lesions found incidentally can encourage patients and practitioners alike to follow closely benign pathologies that may warrant further testing if the discovery differs from baseline in the future.5 The typical features of a benign hepatic cyst include well-circumscribed, thin-walled, anechoic, size <5 cm and lack of inclusions or debris. Rarely, exceptions to seemingly benign hepatic cysts include isolated polycystic liver disease, associated polycystic kidney disease, parasitic infections, cystic tumors, and other syndromes by association. Size >5 cm can be associated with pain and rupture.6 The triage and implications of cystic liver disease are beyond the scope of usual anesthesia practice. In this situation, per the algorithm (Figure 2), the model was advised of the finding, additional information was obtained to determine any associated worrisome symptoms, and, once the asymptomatic nature was established, the model was advised to seek a follow-up opinion from her primary care provider. In situations like this, it is important to acknowledge one’s limitation to avoid patient anxiety, increased medical costs, and inappropriate management. While a meaningful discussion is warranted, further recommendations cautiously should be given advocating a consult with the appropriate specialist.

Government legislation and advisories provide recommendations regarding incidental discoveries. The Presidential Commission for the Study of Bioethical Issues recommends telling patients the presence of incidental discoveries and beginning the discussion of follow-up care.7 The Commonwealth of Massachusetts Board of Registration in Medicine Quality and Patient Safety Division suggests guidelines for incidental findings on imaging. Although not specific to the anesthesiologists, there have been legal judgments with other specialists for failure of disclosure of incidental findings. At the federal and state level, the consensus is that the physician has an obligation to disclose all relevant information to the patient. If an incidental finding is discovered and not disclosed to the patient, the physician can be held liable for failure of disclosure. This is especially relevant if disclosure could have prevented harm.8,9

In summary, it is important to recognize that POC imaging introduces new issues. Anesthesiologists who use POC ultrasound frequently will benefit from broadening their knowledge on common incidental findings and developing a strategy for patient discussion and follow-up. We recommend an example of a strategy that is consistent with the literature of other professionals facing incidental discoveries far more commonly than the average anesthesiologist.

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DISCLOSURES

Name: Aysha Hasan, MD.

Contribution: This author helped design, analyze, and interpret the data, and draft, revise, and edit the manuscript.

Name: Walid Alrayashi, MD.

Contribution: This author helped draft, revise, and edit the manuscript.

Name: David Waisel, MD.

Contribution: This author helped edit and revise the manuscript.

Name: Karen Boretsky, MD.

Contribution: This author helped design, analyze, and interpret the data, and draft, revise and edit the manuscript.

This manuscript was handled by: Raymond C. Roy, MD.

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REFERENCES

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