An unexpected liver lesion?

T De Somer, De Somer T, T Somer, M D'Hondt, M. D’Hondt, D'Hondt M, K Carels, Carels K, Kenneth Carels, Monsaert E, Els Monsaert, E Monsaert, Bouderez V, V Bouderez, Vincent Bouderez, E Vanderstraeten, Erik Vanderstraeten, Vanderstraeten E, H Alaerts, Alaerts H, Herwig Alaerts, C Van Steenkiste, Christophe Van Steenkiste
Acta gastro-enterologica Belgica · 2021 · vol. 84(2) , pp. 385–386 · doi:10.51821/84.2.385 · PMID:34217196 · W3177633605
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⚙ AI-generated summary by gemini-2.5-flash-lite, 2026-06-10 ⓘ

A 50-year-old woman with elevated liver enzymes presented with abdominal pain and was found via CT scan to have a large, complex liver lesion measuring 29x17x22 cm.

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This case report describes a 50-year-old woman with right upper abdominal pain and mildly elevated liver enzymes, in whom CT identified a large right-liver-lobe cystic lesion with a “cyst within cyst” appearance and compression of surrounding tissue. Using contrast-enhancing findings on CT and MRI features suggestive of hemorrhagic content, the lesion was surgically explored and resected; intraoperatively, 3 liters of serosanguineous and 3 liters of serous fluid were evacuated, and histopathology demonstrated an endometrial cyst with endometrial-type epithelium and stroma and intraluminal blood and macrophages. The authors emphasize that preoperative diagnosis is difficult and that the diagnosis can require operative confirmation, with an additional caveat that the lesion was actually against the liver rather than being a true intrahepatic liver lesion. Relevance to endometriosis: the paper’s diagnosis is hepatic endometrial (endometriosis) cyst and it discusses hepatic endometriosis as rare and challenging to diagnose preoperatively, even though the main format is a single clinical image/case report rather than broader mechanistic research.

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Abstract

A 50-year-old woman presented with pain in her right upper abdomen. In her medical history we note a Caesarean section and a laparotomy with bilateral ovariectomy because of benign cysts. The liver enzymes were mildly elevated: aspartate transaminase 40 U/l (reference < 32 U/l), alanine transaminase 53 U/l (reference < 31 U/l), gamma-glutamyl transferase 97 U/l (reference 5 – 36). Computed tomography (CT) revealed a large lesion in the right liver lobe with a cyst within cyst appearance and with important compression of the surrounding tissue (figure 1, panel A). The total diameter measured 29 cm by 17 cm by 22 cm.
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Discussion

A small, contrast enhancing proliferation was seen anteromedially in the peripheral cyst (figure 1, panel A). Magnetic resonance imaging (MRI) showed a watery content in the internal cyst (high signal on T2 and low on T1) and a hyperintense T1 signal in the peripheral cyst, suggestive for hemorrhagic content. During laparoscopic exploration both cysts were incised with evacuation of 3 liters of serosanguineous and 3 liters of serous fluid. Subsequently, the whole cystic lesion was resected (figure 2, panel A). Histopathological examination revealed the diagnosis of an endometrial cyst (figure 2, panel B). Endometriosis is defined as the presence of endometrial tissue outside the uterus (1,2). Hepatic endometrial cysts appear to be rare with only case reports available in the literature. Preoperative diagnosis is challenging, since no clinical or radiological findings are characteristic (2,3). As a consequence, surgery is the next step for both diagnostic confirmation and treatment (1,3). Since perioperative frozen sections can confirm the diagnosis, radical hepatectomy sometimes can be avoided and pericystectomy can be performed (2,3). Unlike the other possible diagnoses this endometrial cyst was not actually a liver lesion, but a lesion against the liver. Conflicts of interest None declared.

Keywords

Abdominal pain, endometrial cyst, hepatic endometriosis. Correspondence to : Thomas De Somer, Buitenring Sint-Denijs 30, 9000 Gent, Belgium. Fax : 09/246.71.09. Email : [email protected] Submission date : 04/05/2020 Acceptance date : 30/06/2020 Acta Gastro-Enterologica Belgica, Vol. 84, April-June 2021 CLINICAL IMAGE— DOI 10.51821/84.2.385 385 Figure 1. — panel A: contrast enhanced axial computed tomography image: spontaneous isodense aspect of the peripheral cyst and hypodense aspect of the internal cyst, arrow: small contrast enhancing proliferation; panel B: perioperative image after incision of the peripheral cyst. Figure 2. — panel A: image of the resected lesion; panel B: histopathological image (magnification x 100) with intraluminal blood and macrophages, endometrial type epithelium and endometrial stroma in the wall of the cyst. 386 T. De Somer et al. Acta Gastro-Enterologica Belgica, Vol. 84, April-June 2021 outcomes of hepatic endometriosis: A systematic review. Ann. Hepatol., 2020, 19(1) : 17-23. 3. ANDRES M.P., ARCOVERDE F.V .L., SOUZA C.C.C., FERNANDES L.F.C., ABRAO M.S., KHO R.M. Extrapelvic endometriosis: A systematic review. J. Minim. Invasive Gynecol., 2020, 27(2) : 373-89.

References

1. ZONDERV AN K.T., BECKER C.M., MISSMER S.A. Endometriosis. N. Engl. J. Med., 2020, 382(13) : 1244-56. 2. PRODROMIDOU A., MACHAIRAS N., PASPALA A., HASEMAKI N., SOTIROPOULOS G.C. Diagnosis, surgical treatment and postoperative

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Condition tags

endometriosis

MeSH descriptors

Endometriosis Endometriosis Liver Diseases Liver Diseases Liver Neoplasms Liver Neoplasms Diagnosis, Differential Female Humans

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