1. Missing Cirrhosis on CT Scan

2. History 33 year old male referred for cirrhosis and liver masses
Abnormal LFT’s since 1992
PMH of DM, HTN, dyslipidemia and migraine
No alcohol and quit smoking
Home meds – pioglitazone, metformin, ursodiol, olmesartan, liothyronine, insulin

3. Exam Vitals stable, BMI of 39 Alert and oriented No icterus
Enlarged liver and spleen
No ascites or edema

4. Laboratory Data Hemoglobin 15.1 WBC 6.1 Platelets 134 INR 1.0
AST 41, ALT 50
Alk phosphatase 83
T. Bilirubin 0.6
Albumin – 4.5
INR – 1.0
MELD score of 6
ANA, AMA, AMA M2, ASMA, ceruloplasmin, Cu, ferritin and hepatitis panel – negative
Alpha1-AT level normal and phenotype MM

5. MRI 9/28/07
Nodules 3x4 cm and 3x2.5 cm

6. Nodules 3x4 cm and 3x2 cm
MRI 12/28/07

7. MRI 6/23/08

8. Summary Outside MRI – nodules in the right lobe
9/07 – 3x4 cm and 3x2.5 cm
12/07 – 3x4 cm and 3.5x2cm
6/08 – 4.7x3.9 cm and 4.5x3.2cm
Repeat CT and MRI (10/08) – no masses
AFP 4 (11/07)  3 (6/08)  3.4 (10/08)

9. Follow-up triple phase CT (10/22/08)

10. Follow-up triple phase CT (1/16/09)

11. Work Up NO varices on EGD Etiology is NASH related cirrhosis
Diagnostic laparoscopy

13. Pathology
Liver biopsy in 10/07 – cirrhosis with moderate fatty degeneration and mild nonspecific portal inflammation with bile ductular proliferation
Liver biopsy in 10/08 – cirrhosis with mild steatosis (30%), glycogenated nuclei, and chronic inflammation (from the nodule)