Diagnosis and Management of Focal Liver Lesions

Publication Date: July 2, 2024
Last Updated: July 3, 2024


In patients with an FLL of uncertain etiology, we recommend multiphasic contrast-enhanced imaging, preferably MRI or CT performed with late arterial, portal venous, and delayed phases.

(S, L )

Hepatic Adenoma

We recommend discontinuation of OCPs or intrauterine devices that are hormone-impregnated in patients with hepatic adenomas.

(S, L )

We suggest encouraging weight loss in overweight or obese patients with hepatic adenomas. (C, VL )

We suggest using multiphasic liver imaging (preferable MRI) over standard cross-sectional imaging modalities to accurately distinguish hepatic adenomas from other benign or malignant liver lesions. (C, VL )

In women with hepatic adenomas <5 cm, we suggest discontinuation of exogenous hormones and advise weight loss, if applicable, for overweight or obese individuals. (C, VL )

In women with hepatic adenomas <5 cm, we suggest surveillance with contrast-enhanced imaging modalities every 6 months for 2 years, then annually thereafter. (C, L )

In patients with hepatic adenomas requiring treatment who are unable to undergo surgical resection, we suggest embolization or ablation as alternative treatment approaches. (C, L )

In patients with ruptured hepatic adenomas, we suggest hemodynamic stabilization followed by embolization and/or surgical resection. (C, VL )

Focal Nodular Hyperplasia

We suggest evaluating patients with FLLs that are suspicious for FNH using multiphase MRI with hepatobiliary-specific contrast agents to distinguish FNH from HCA.

(C, L )

We do not suggest routinely discontinuing OCPs in patients diagnosed with FNH. (C, VL )


In patients with cirrhosis or chronic hepatitis B who meet criteria for HCC surveillance and have a suspected hemangioma, we recommend continued imaging surveillance every 3–6 months for at least 1 year.

(S, L )

Simple Hepatic Cysts

In patients with asymptomatic simple hepatic cysts, regardless of size, we recommend expectant management without need for routine surveillance or intervention.

(S, L )

In patients with simple hepatic cysts with specific high-risk features seen on ultrasound (e.g., septations, fenestrations, calcifications, mural thickening or nodularity, heterogeneity, and presence of daughter cysts), we recommend further investigation with CT or MRI. (S, L )

We suggest surgical cyst fenestration or aspiration with sclerotherapy for management of patients with symptomatic simple hepatic cysts. (C, L )

Polycystic Liver Disease

We suggest discontinuation of exogenous estrogen use in women with PCLD. (C, VL )

For patients with PCLD with numerous small- to medium-sized cysts throughout the liver not amenable to surgical resection, cyst fenestration or aspiration sclerotherapy, or for patients with symptomatic ADPKD with concurrent PCLD, we recommend medical management using somatostatin analogs. (S, M )

Hydatid/Echinococcal Cysts

We suggest surgical management in patients with complicated hydatid cysts (i.e., those with biliary fistulas or cysts communicating with the biliary tree, multiseptated cysts, rupture or hemorrhage, secondary infection, or percutaneously inaccessible cysts) provided there is no contraindication to surgery. (C, VL )

In patients with uncomplicated hydatid cysts in whom surgery is not an option, we suggest percutaneous treatment with puncture, aspiration, injection of scolicidal agent, and reaspiration with adjunct antihelminthic therapy. (C, L )

Recommendation Grading



Focal Liver Lesions

Authoring Organization

Publication Month/Year

July 2, 2024

Last Updated Month/Year

July 8, 2024

Supplemental Implementation Tools

Document Type


External Publication Status


Country of Publication


Document Objectives

Focal liver lesions (FLLs) have become an increasingly common finding on abdominal imaging, especially asymptomatic and incidental liver lesions. Gastroenterologists and hepatologists often see these patients in consultation and make recommendations for management of multiple types of liver lesions, including hepatocellular adenoma, focal nodular hyperplasia, hemangioma, and hepatic cystic lesions including polycystic liver disease. Malignancy is important to consider in the differential diagnosis of FLLs, and healthcare providers must be familiar with the diagnosis and management of FLLs. This American College of Gastroenterology practice guideline uses the best evidence available to make diagnosis and management recommendations for the most common FLLs

Target Patient Population

Patients with focal liver lesions

Inclusion Criteria

Male, Female, Adolescent, Adult, Older adult

Health Care Settings

Ambulatory, Hospital, Outpatient, Operating and recovery room

Intended Users

Nurse, nurse practitioner, physician, physician assistant


Diagnosis, Assessment and screening, Management

Diseases/Conditions (MeSH)

D008107 - Liver Diseases, D008099 - Liver, D008103 - Liver Cirrhosis


liver disease, hepatitis, cystic lesions, liver lesions

Source Citation

Frenette, Catherine MD1; Mendiratta-Lala, Mishal MD2; Salgia, Reena MD3; Wong, Robert J. MD, MS, FACG4; Sauer, Bryan G. MD, MSc, FACG5; Pillai, Anjana MD, FACG6. ACG Clinical Guideline: Focal Liver Lesions. The American Journal of Gastroenterology 119(7):p 1235-1271, July 2024. | DOI: 10.14309/ajg.0000000000002857