SYB Case #2 Jordan Torok Class of 2010 December 11 th, 2008

CC:

54-year-old white male with biopsy-proven cirrhosis secondary to hepatitis C (diagnosed 11 years ago) 54-year-old white male with biopsy-proven cirrhosis secondary to hepatitis C (diagnosed 11 years ago) Clinical: hepatomegaly, anicteric, no evidence of varcies but possible hepatic encephalopathy based on history Clinical: hepatomegaly, anicteric, no evidence of varcies but possible hepatic encephalopathy based on history Laboratory: AST 107Tbil 1.3 Laboratory: AST 107Tbil 1.3 GGTP 385ALT 84AlkP 194 Albumin 3.6AFP 5.8NH3 50

CT findings of Cirrhosis Fatty infiltration-reduces CT attenuation of involved liver parenchyma (liver normally >10 HU than spleen) Fatty infiltration-reduces CT attenuation of involved liver parenchyma (liver normally >10 HU than spleen) Heterogeneous parenchymal attenuation- due to patchy fatty infiltration and irregular fibrosis Heterogeneous parenchymal attenuation- due to patchy fatty infiltration and irregular fibrosis Irregular lobulated or nodular contour Irregular lobulated or nodular contour Hepatomegaly during active injury, progressive cirrhosis deforms and shrinks liver Hepatomegaly during active injury, progressive cirrhosis deforms and shrinks liver Atrophy of right lobe, hypertrophy of left and caudate lobes (alcoholic micronodular cirrhosis) Atrophy of right lobe, hypertrophy of left and caudate lobes (alcoholic micronodular cirrhosis) Nodular lesions: regenerative, dysplastic or HCC Nodular lesions: regenerative, dysplastic or HCC

CT findings of Portal HTN Portosystemic collateral vessel enlargement Portosystemic collateral vessel enlargement Esophageal, paraesophageal and gastric varices; varices appear as round, serpentine structures Esophageal, paraesophageal and gastric varices; varices appear as round, serpentine structures Portal vein > 13 mm Portal vein > 13 mm Splenic and superior mesenteric veins > 10 mm Splenic and superior mesenteric veins > 10 mm Splenomegaly Splenomegaly Ascites Ascites

Hepatocellular Carcinoma 4 cases per 100,000 4 cases per 100,000 Common causes in the U.S. include alcoholic cirrhosis, steroid use and hemochromatosis Common causes in the U.S. include alcoholic cirrhosis, steroid use and hemochromatosis Common causes internationally include hepatitis B/C and aflatoxin exposure Common causes internationally include hepatitis B/C and aflatoxin exposure HCC seen mostly in patients older than 50 HCC seen mostly in patients older than 50 Up to 40% of HCCs are missed in cirrhotic livers Up to 40% of HCCs are missed in cirrhotic livers Significant morbidity and mortality Significant morbidity and mortality

CT findings of HCC Tumor growth may be solitary (50%), diffuse infiltrative (30%) or multinodular (20%) Tumor growth may be solitary (50%), diffuse infiltrative (30%) or multinodular (20%) Arterial hypervascularity is a hallmark finding Arterial hypervascularity is a hallmark finding Small tumors (<3cm) hypo- or isointense on non-contrast, demonstrate bright homogenous enhancement on arterial phase Small tumors (<3cm) hypo- or isointense on non-contrast, demonstrate bright homogenous enhancement on arterial phase Large tumors are hypodense on non-contrast and enhance heterogeneously on both arterial and portal venous phases Large tumors are hypodense on non-contrast and enhance heterogeneously on both arterial and portal venous phases Areas of tumor necrosis and calcification may be seen Areas of tumor necrosis and calcification may be seen Low attenuation fibrous capsule that enhances on portal venous phase and delayed images characteristic Low attenuation fibrous capsule that enhances on portal venous phase and delayed images characteristic Tumor invasion of hepatic and portal veins frequent in advanced cases, likely to be associated with portal vein thrombosis Tumor invasion of hepatic and portal veins frequent in advanced cases, likely to be associated with portal vein thrombosis

Abdomen: The liver is enlarged, measuring 23 cm in the craniocaudal dimension. There is marked nodular contour to the liver. There is a 2 x 1.6 cm lesion near the dome of the right lobe of the liver, which is hypodense on the non-contrast, hyperdense on the arterial phase, and demonstrates early washout in the venous phase. The second hyperdense nodule seen in the lower cuts of the recent chest CT in segment 4A does not enhance on today’s examination and is most likely a regenerating nodule. There are gastroesophageal and splenic varices. The portal vein is enlarged and measuring approximately 27 mm in greatest dimension. There is marked splenomegaly. The gallbladder is decompressed, with a single calcified gallstone. The pancreas is normal in appearance. There is no intra-or extrahepatic bile duct dilation. The kidneys are normal in appearance. There is no hydronephrosis or ureteral dilation. There is no lymphadenopathy or free fluid. The visualized bowel is normal in caliber. The osseous structures are normal for age. There is a fat containing umbilical hernia. Abdomen: The liver is enlarged, measuring 23 cm in the craniocaudal dimension. There is marked nodular contour to the liver. There is a 2 x 1.6 cm lesion near the dome of the right lobe of the liver, which is hypodense on the non-contrast, hyperdense on the arterial phase, and demonstrates early washout in the venous phase. The second hyperdense nodule seen in the lower cuts of the recent chest CT in segment 4A does not enhance on today’s examination and is most likely a regenerating nodule. There are gastroesophageal and splenic varices. The portal vein is enlarged and measuring approximately 27 mm in greatest dimension. There is marked splenomegaly. The gallbladder is decompressed, with a single calcified gallstone. The pancreas is normal in appearance. There is no intra-or extrahepatic bile duct dilation. The kidneys are normal in appearance. There is no hydronephrosis or ureteral dilation. There is no lymphadenopathy or free fluid. The visualized bowel is normal in caliber. The osseous structures are normal for age. There is a fat containing umbilical hernia. IMPRESSION: IMPRESSION: 1. Single hypervascular lesion near the dome of the liver, as described above, concerning for hepatocellular carcinoma. The second nodule in segment IVA is likely a regenerating nodule. 1. Single hypervascular lesion near the dome of the liver, as described above, concerning for hepatocellular carcinoma. The second nodule in segment IVA is likely a regenerating nodule. 2. Cirrhosis with portal hypertension. 2. Cirrhosis with portal hypertension. 3. Classic hepatic arterial anatomy without celiac artery stenosis. 3. Classic hepatic arterial anatomy without celiac artery stenosis.