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Focal liver lesions

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Updated 2024 ACG guidelines for the evaluation and management of focal liver lesions.

Guidelines

Key sources

The following summarized guidelines for the evaluation and management of focal liver lesions are prepared by our editorial team based on guidelines from the American College of Gastroenterology (ACG 2024), the European Association for the Study of the Liver (EASL 2022,2016), the American College of Radiology (ACR 2020), the European Federation of Societies for Ultrasound (EFSU 2020), and the Spanish ...
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Diagnostic investigations

Initial evaluation
As per ACG 2024 guidelines:
Obtain the following in the evaluation of asymptomatic patients without known liver disease and an incidentally detected liver lesion:
Situation
Guidance
Patient history
History of previous cancer
Constitutional symptoms
Weight loss, loss of appetite, and fever
Medication history
Oral contraceptives and steroids
Risk factors for chronic liver disease
Viral hepatitis, transfusion history, tattoos, intravenous drug use, and alcohol excess
Features of metabolic syndrome
Obesity, dyslipidemia, insulin resistance, hypertension, and CVD
Blood tests
Liver enzymes, tumor markers, and viral hepatitis panel
Contrast-enhanced imaging
Contrast-enhanced ultrasound, MRI, and CT
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Consider reviewing inadequately characterized and/or atypical focal liver lesions at a multidisciplinary liver tumor board.
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  • Contrast-enhanced ultrasound

  • Cross-sectional imaging

Specific circumstances

Patients with simple hepatic cysts, evaluation: as per ACG 2024 guidelines, obtain further evaluation with CT or MRI in patients with simple hepatic cysts with specific high-risk features seen on ultrasound (such as septations, fenestrations, calcifications, mural thickening or nodularity, heterogeneity, and presence of daughter cysts).
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  • Patients with simple hepatic cysts (management)

  • Patients with simple hepatic cysts (surveillance)

  • Patients with choledochal cysts

  • Patients with polycystic liver disease (evaluation)

  • Patients with polycystic liver disease (management)

  • Patients with hepatic hemangioma

  • Patients with focal nodular hyperplasia

  • Patients with hepatic mucinous cystic neoplasms

  • Patients with biliary cysts and neoplasms

  • Patients with hepatocellular adenoma

  • Patients with hepatic endothelial hemangioendothelioma

  • Patients with HCC

  • Patients with hepatic hemangiosarcoma

  • Patients with liver metastasis

  • Patients with hydatid cysts