Obstructive cholestasis without biliary dilatation from a hepatic cyst

Simple hepatic cysts are usually benign and asymptomatic but may rarely cause cholestasis from biliary compression. We report a man in his 70s with a recurrent large haemorrhagic hepatic cyst who developed right upper quadrant pain, early satiety, dark urine and marked obstructive-pattern liver injury despite repeated CT and magnetic resonance cholangiopancreatography showing no intrahepatic or extrahepatic biliary ductal dilatation. Percutaneous aspiration produced partial biochemical improvement, but symptoms and cholestasis persisted with cyst recurrence. Definitive robotic cyst fenestration resulted in rapid improvement and sustained resolution of hyperbilirubinaemia at follow-up. This case highlights that cyst-related biliary obstruction may be clinically and biochemically significant even without ductal dilatation on imaging. In patients with compatible symptoms, cholestatic liver chemistry abnormalities and a cyst anatomically capable of biliary compression, absence of ductal dilatation should not exclude cyst-related obstruction.