SYB Case #2SYB Case #2Jordan TorokJordan TorokClass of 2010Class of 2010

December 11December 11thth, 2008, 2008

CC:CC:

54-year-old white male with biopsy-54-year-old white male with biopsy-proven cirrhosis secondary to proven cirrhosis secondary to hepatitis C (diagnosed 11 years ago)hepatitis C (diagnosed 11 years ago)

Clinical: hepatomegaly, anicteric, no Clinical: hepatomegaly, anicteric, no evidence of varcies but possible evidence of varcies but possible hepatic encephalopathy based on hepatic encephalopathy based on historyhistory

Laboratory: Laboratory: AST 107AST 107 Tbil 1.3Tbil 1.3GGTP 385GGTP 385 ALT 84ALT 84 AlkP 194AlkP 194Albumin 3.6Albumin 3.6 AFP 5.8AFP 5.8 NH3 50NH3 50

CT findings of Cirrhosis CT findings of Cirrhosis Fatty infiltration-reduces CT attenuation of Fatty infiltration-reduces CT attenuation of

involved liver parenchyma (liver normally >10 involved liver parenchyma (liver normally >10 HU than spleen)HU than spleen)

Heterogeneous parenchymal attenuation- due to Heterogeneous parenchymal attenuation- due to patchy fatty infiltration and irregular fibrosis patchy fatty infiltration and irregular fibrosis

Irregular lobulated or nodular contour Irregular lobulated or nodular contour Hepatomegaly during active injury, progressive Hepatomegaly during active injury, progressive

cirrhosis deforms and shrinks livercirrhosis deforms and shrinks liver Atrophy of right lobe, hypertrophy of left and Atrophy of right lobe, hypertrophy of left and

caudate lobes (alcoholic micronodular cirrhosis) caudate lobes (alcoholic micronodular cirrhosis) Nodular lesions: regenerative, dysplastic or HCCNodular lesions: regenerative, dysplastic or HCC

CT findings of Portal CT findings of Portal HTNHTN

Portosystemic collateral vessel Portosystemic collateral vessel enlargementenlargement Esophageal, paraesophageal and gastric Esophageal, paraesophageal and gastric

varices; varices appear as round, serpentine varices; varices appear as round, serpentine structuresstructures

Portal vein > 13 mmPortal vein > 13 mm Splenic and superior mesenteric veins > 10 Splenic and superior mesenteric veins > 10

mmmm SplenomegalySplenomegaly AscitesAscites

Hepatocellular Hepatocellular CarcinomaCarcinoma

4 cases per 100,0004 cases per 100,000 Common causes in the U.S. include Common causes in the U.S. include

alcoholic cirrhosis, steroid use and alcoholic cirrhosis, steroid use and hemochromatosishemochromatosis

Common causes internationally include Common causes internationally include hepatitis B/C and aflatoxin exposure hepatitis B/C and aflatoxin exposure

HCC seen mostly in patients older than 50HCC seen mostly in patients older than 50 Up to 40% of HCCs are missed in Up to 40% of HCCs are missed in

cirrhotic liverscirrhotic livers Significant morbidity and mortality Significant morbidity and mortality

CT findings of HCCCT findings of HCC Tumor growth may be solitary (50%), diffuse infiltrative Tumor growth may be solitary (50%), diffuse infiltrative

(30%) or multinodular (20%)(30%) or multinodular (20%) Arterial hypervascularity is a hallmark findingArterial hypervascularity is a hallmark finding Small tumors (<3cm) hypo- or isointense on non-contrast, Small tumors (<3cm) hypo- or isointense on non-contrast,

demonstrate bright homogenous enhancement on arterial demonstrate bright homogenous enhancement on arterial phasephase

Large tumors are hypodense on non-contrast and enhance Large tumors are hypodense on non-contrast and enhance heterogeneously on both arterial and portal venous phasesheterogeneously on both arterial and portal venous phases

Areas of tumor necrosis and calcification may be seenAreas of tumor necrosis and calcification may be seen Low attenuation fibrous capsule that enhances on portal Low attenuation fibrous capsule that enhances on portal

venous phase and delayed images characteristic venous phase and delayed images characteristic Tumor invasion of hepatic and portal veins frequent in Tumor invasion of hepatic and portal veins frequent in

advanced cases, likely to be associated with portal vein advanced cases, likely to be associated with portal vein thrombosisthrombosis

Abdomen: The Abdomen: The liver is enlargedliver is enlarged, measuring 23 cm in the , measuring 23 cm in the craniocaudal dimension. There is marked craniocaudal dimension. There is marked nodular contour to nodular contour to the liverthe liver. There is a 2 x 1.6 cm lesion near the dome of the right . There is a 2 x 1.6 cm lesion near the dome of the right lobe of the liver, which is lobe of the liver, which is hypodensehypodense on the non-contrast, on the non-contrast, hyperdensehyperdense on the arterial phase, and demonstrates early on the arterial phase, and demonstrates early washout in the venous phase. The second hyperdense nodule washout in the venous phase. The second hyperdense nodule seen in the lower cuts of the recent chest CT in segment 4A does 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 not enhance on today’s examination and is most likely a regenerating nodule. There are regenerating nodule. There are gastroesophageal and splenic gastroesophageal and splenic varicesvarices. The . The portal vein is enlargedportal vein is enlarged and measuring and measuring approximately 27 mm in greatest dimension. There is approximately 27 mm in greatest dimension. There is marked marked splenomegalysplenomegaly. The gallbladder is decompressed, with a single . The gallbladder is decompressed, with a single calcified gallstone. The pancreas is normal in appearance. There calcified gallstone. The pancreas is normal in appearance. There is no intra-or extrahepatic bile duct dilation. The kidneys are is no intra-or extrahepatic bile duct dilation. The kidneys are normal in appearance. There is no hydronephrosis or ureteral normal in appearance. There is no hydronephrosis or ureteral dilation. There is no lymphadenopathy or free fluid. The dilation. There is no lymphadenopathy or free fluid. The visualized bowel is normal in caliber. The osseous structures are visualized bowel is normal in caliber. The osseous structures are normal for age. There is a fat containing umbilical hernia.normal for age. There is a fat containing umbilical hernia.

IMPRESSION: IMPRESSION: 1. Single hypervascular lesion near the dome of the liver, as 1. Single hypervascular lesion near the dome of the liver, as

described above, described above, concerning for hepatocellular carcinomaconcerning for hepatocellular carcinoma. The . The second nodule in segment IVA is likely a regenerating nodule.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.