Typically, patients are clinically asymptomatic with an unremarkable physical exam as the diagnosis is usually incidental on laparotomy for another procedure. Rarely, patients can present with fevers, jaundice, abdominal distension, and right upper quadrant or epigastric pain.[3][8][9]

As a result of the incidental and usually benign nature of multiple biliary duct hamartomas, no evaluation is necessary for the diagnosis. However, while most patients will have normal lab results, some can present with mild elevations in liver function tests, specifically aspartate aminotransferase (AST) and gamma-glutamyl transpeptidase (GGT). Typically these lesions are found initially on ultrasound or computed tomography (CT) done for a different reason. On ultrasound, these lesions appear as multiple hyper and hypoechoic areas within the liver with comet-tail artifacts. On CT, they appear as multiple, nodular, irregular cystic liver lesions with low attenuation and no enhancement with intravenous contrast injection. The most sensitive imaging modality is magnetic resonance imaging or magnetic resonance cholangiopancreatography (MRI/MRCP), which shows multiple T1 hypointense and T2 hyperintense diffuse cystic liver lesions of variable sizes 0.1 to 1.5 cm which do not communicate with the biliary tree and do not enhance with intravenous gadolinium injection.[8][9][12] The most specific finding on MRCP for biliary duct hamartomas is mural nodules, which are endocytic polypoid projections due to conjunctive septa that are isointense on T1-weighted images and hyperintense on T2-weighted images. The presence of mural nodules can help diagnose multiple biliary duct hamartomas with accuracy and help avoid misdiagnosis.[13]

Aside from the possible risk of malignant transformation, multiple biliary duct hamartomas is a benign, otherwise asymptomatic condition with no long-term adverse outcomes and no treatment is required.[9] However, suspicious lesions should be followed regularly with repeat imaging and possible liver biopsy for definitive diagnosis. Any changes of the lesion on repeat imaging or any elevations from tumor markers from baseline should warrant further workup with possible surgical resection when the diagnosis is definitive, and the lesion is operable.[4][9]

The diagnosis of multiple biliary duct hamartomas is usually incidental at autopsy or on radiographic imaging. However, when discovered on imaging, it is important to determine a correct diagnosis due to its close resemblance to metastatic disease of the liver, especially in a patient with extra-hepatic malignant tumors. Typically, liver metastases are ill-defined with variable sizes on plain computed tomography (CT) imaging with varying degrees of enhancement with IV contrast.[3] Bile duct hamartomas, on the contrary, typically do not enhance with IV contrast on CT imaging, are usually uniform, and measure 1 to 15 mm in size.[2]

Other differential diagnoses include bile duct adenomas, peribiliary cysts, microabscesses of the liver, intrahepatic biliary stones, and Caroli’s disease. Bile duct adenomas have small round tubules with small inconspicuous lumens while bile duct hamartomas have dilated lumens with inspissated bile.[2] Peribiliary cysts are located specifically within the hepatic hilum within connective tissue along the portal vein, do not communicate with the biliary tree, and typically enlarge and compress the biliary tree over time, which is contrasted to the diffuse scattered nature of biliary duct hamartomas.[3][3][7] Microabscesses of the liver are usually present as multiple round loculated hypodense lesions on CT. They are seen in patients with immunosuppression, fever, and epigastric pain, which can be differentiated from bile duct hamartomas by signs of sepsis, which are not typically seen in the latter.[3] Caroli’s disease is characterized by intrahepatic bile duct dilation communicating with the biliary tree, differentiated from bile duct hamartomas with MRCP by contrast enhancement with intravenous gadolinium.[3][12]

The clinical problem posed by this benign tumor is for the surgeon or surgical oncologist who encounters such a lesion during a laparotomy for another malignant lesion. Typically, the surgeon will perform a liver biopsy for frozen section once this lesion is encountered. It can be difficult to distinguish benign hamartomas from metastatic disease in the liver. The pathologist who receives the specimen for frozen section, who is unaware of this entity, may label the lesion as metastatic carcinoma or Carolis' disease. However, these lesions do not communicate with bile ducts, and no treatment is necessary.

Due to the asymptomatic clinical course in most and incidental findings at autopsy for patients who die of unrelated diseases, the prognosis is typically great. However, patients who have malignant transformation typically have a very poor 5-year survival rate of 15 to 40%.[14]

There are small subsets of patients who experience a malignant transformation of multiple biliary duct hamartomas to either intrahepatic cholangiocarcinoma (more common) or hepatocellular carcinoma. Risk factors for possible malignant transformation include long-term tobacco use, large biliary duct hamartomas (> 2 cm), and bile stasis.[15] It is important to have periodic long-term follow-up with these patients with a definitive diagnosis of multiple biliary duct hamartomas. Patients require a baseline CA 19-9 level, which can be slightly elevated with multiple biliary duct hamartomas. Any changes to MRI/MRCP imaging in addition to elevations in tumor markers warrants further evaluation with liver lesion biopsy and possible resection of lesions if operable with a definitive diagnosis.[9]

Educational materials for the patient as well as clinicians should include: 

• Full understanding of the wide differential diagnoses for multiple biliary duct hamartomas 
• Specific findings on ultrasound, computed tomography, and magnetic resonance imaging 
• importance of long-term follow-up for these patients due to possible malignant transformation to help prevent adverse outcomes

Patients with multiple biliary duct hamartoma typically require no extensive workup. However, it is important that radiologists understand this disease and its appearance on imaging to help differentiate it from more malignant or life-threatening liver lesions. Surgeons and oncologists must be aware of this disease in the case of malignant transformation requiring liver resection and chemotherapy or radiation for treatment. Good communication and education with the pathologist and surgeon are paramount to deal with benign liver lesions.