124 Gallbladder Serosal Nodule Due to Ectopic Liver: A Diagnostic Pitfall Mimicking Cancer

Accessory Lobe of Right Liver Mimicking a Pulmonary Tumor in an Adult Male

IntroductionEctopic hepatic tissue is due to an uncommon failure of embryological liver development. The incidence of ectopic liver has been reported to be anywhere from 0.24% to 0.47% and a prevalence rate of 0.47% as diagnosed at laparotomy or laparoscopy. We report a case of Ectopic Hepatic tissue attached to the gallbladder wall that was discovered during a laparoscopic cholecystectomy. Case reportA 47 year-old women presented to the surgery department with abdominal acute pain. The patient was taken for a standard laparoscopic cholecystectomy. The gallbladder was retracted cephalad while Hartmann’s pouch was retracted laterally. It was then noted that an ectopic tissue was present on the gallbladder wall. The patient recovered well after surgery, had no complications and was discharged the day after surgery. DiscussionEctopic hepatic tissue is a rare condition. The real incidence of ectopic hepatic tissue attached to the gallbladder wall is difficult to assess but is reportedly 0.24–0.47% of the population. Ectopic hepatic tissue attached to the gallbladder usually remains asymptomatic and is occasionally discovered during laparoscopy, as was the case with the patient in the present report. In this case presented, the histopathological examination of specimen was confirmed to be ectopic liver tissue without hepatocellular carcinoma. ConclusionIt is important to be vigilant of ectopic hepatic tissue, their complications, and the potential surgical, including increased operative time and the need to follow up on such patients to rule out any possible complications.

A rare condition: Ectopic liver tissue with its unique blood supply encountered during laparoscopic cholecystectomy

Hepatocellular carcinomata are relatively rare in the western hemisphere, but they are much more common in South-East Asia and sub-Saharan Africa due to high endogenous levels of hepatitis B and C. Ectopic liver tissue usually is found incidentally (frequently at cholecystectomy), but it may also be found due to neoplastic changes or compressive effects. Ectopic liver tissue has an increased neoplastic potential over orthotopic liver, which we postulate is due to compromised vascular supply and biliary drainage. These lesions may be susceptible to surgical resection, although long-term follow-up data are poor. Ectopic or accessory liver tissue is a rare condition. Most commonly, it is found incidentally, but it may also be found as a result of neoplasia or compressive effects. These lesions appear to have an increased potential for the development of hepatocellular carcinoma in the absence of malignancy in the mother liver. Due to their anatomical features, these carcinomata appear to be susceptible to curative resection, although long-term follow-up data are poor. These carcinomata have been reported more frequently from South-East Asia than from Western countries; however, the common risk factors for hepatocellular carcinoma, such as infection with hepatitis B or C and cirrhosis, appear to be less implicated than in carcinomata of the orthotopic liver. In ectopic or accessory liver tissue, development of hepatocellular carcinoma may be the result of compromised vascular supply or biliary drainage.

BACKGROUNDLiver tissue situated outside the liver with a hepatic connection is usually called an accessory liver, and that without a connection to the mother liver, is called ectopic liver tissue. AIMTo identify studies in the literature on ectopic liver tissue located on the gallbladder surface or mesentery. METHODSWe present two patients and review published articles on ectopic liver tissue located on the gallbladder surface accessed via PubMed, MEDLINE, Google Scholar, and Google databases. Keywords used included accessory liver lobe, aberrant liver tissue, ectopic liver tissue, ectopic liver nodule, heterotopic liver tissue, hepatic choristoma, heterotopic liver tissue on the gallbladder, and ectopic liver tissue on the gallbladder. The search included articles published before June 2020 with no language restriction. Letters to the editor, case reports, review articles, original articles, and meeting presentations were included in the search. Articles or abstracts containing adequate information on age, sex, history of liver disease, preliminary diagnosis, radiologic tools, lesion size, surgical indication, surgical procedure, and histopathological features of ectopic liver tissue were included in the study.RESULTSA total of 72 articles involving 91 cases of ectopic liver tissue located on the gallbladder surface or mesentery were analyzed. Of these 91 patients, 62 were female and 25 were male (no gender available for 4 patients), and the age range was 5 d to 91 years. Forty-nine patients underwent surgery for chronic cholecystitis or cholelithiasis, and 14 patients underwent surgery for acute cholecystitis. The remaining 28 patients underwent laparotomy for other reasons. Cholecystectomy was laparoscopic in 69 patients and open in 11 patients. The remaining 19 patients underwent various other surgical procedures such as autopsy, liver transplantation, living donor hepatectomy, Whipple procedure, and liver segment V resection. Histopathologically, hepatocellular carcinoma was detected in the ectopic liver tissue of one patient. CONCLUSIONEctopic liver tissue is a rare developmental anomaly which is usually detected incidentally. Although most studies suggest that ectopic liver located outside the gallbladder has a high risk of hepatocellular carcinoma, this is not reflected in statistical analysis.

Introduction: Ectopic liver tissue (ELT) is seldom reported in the literature. It is usually asymptomatic and incidentally found. However, ELT has a strong association with malignant transformation to hepatocellular carcinoma (HCC), making removal of this tissue essential. Presented is a rare case of ELT found in the stomach. Case Description/Methods: A 78-year-old male with a past medical history of hypertension and gastritis presented to clinic for worsening gastroesophageal reflux disease (GERD) over the past six months. The patient reported GERD symptoms for the past twenty years that he had been self-treating with over-the-counter proton pump inhibitors, probiotics, and digestive enzymes without relief. On presentation his vitals, physical exam, and blood work were unremarkable. The patient underwent esophagoduodenoscopy (EGD) which revealed esophagitis, a large paraesophageal hernia, and a single 15-millimeter submucosal nodule in the anterior wall of the gastric body. Cold forceps biopsies obtained from the body and antrum of the stomach were unremarkable and negative for H. pylori. He was referred for endoscopic ultrasound (EUS), where a fine needle biopsy of the benign-appearing gastric body submucosal nodule was performed (figure 1a). Three passes were made with a 22-gauge ultrasound biopsy needle using a transgastric approach. A visible core of tissue was obtained. Final cytology demonstrated superficial gastric mucosa and detached benign liver tissue (figures 1b, 1c). No dysplasia or malignancy was seen. Discussion: ELT has an incidence of 0.24-0.47%. Of the reported cases, ELT is most commonly seen in the gallbladder or pancreas. The etiology of ELT is unknown but is thought to be associated with errors in embryological development. Most ELT is asymptomatic but can develop the same pathologies as the orthotopic liver. It can also cause abdominal pain, bleeding, and compression of neighboring tissues. There is also a strong association between HCC and ELT, necessitating biopsy and endoscopic removal. This case demonstrated ELT incidentally found in the gastric body during EGD and was biopsied by a fine needle using EUS guidance. Histology was without features to suggest malignancy, but to prevent malignant transformation endoscopic resection was recommended.Figure 1.: 1a. Arrow indicating nodule in gastric body, as seen by endoscopic ultrasound. Image 1b. Hematoxylin and eosin stain with 100x magnification. Normal gastric glandular mucosa. Arrow indicating benign unremarkable hepatic tissue found in gastric body. Image 1c. Hematoxylin and eosin stain with 200x magnification. Benign unremarkable hepatic tissue found in gastric body.

Introduction: Ectopic liver tissue is a rare entity. It can be found in various organs of the body but the most common reported location is the gallbladder. The incidence is varying between 0.27% and 0.47%. Most of the cases are asymptomatic and diagnosed intra-operatively or during autopsy. We report a case of Gallbladder-Associated ectopic liver tissue that was encountered during a laparoscopic cholecystectomy. Case presentation: A 40-year-old female patient was admitted to the hospital for laparoscopic cholecystectomy for symptomatic gallstones, intra-operatively we found an ectopic liver tissue attached to the gallbladder wall. Cholecystectomy was performed and the patient was discharged home the day after surgery in good condition. The histopathological examination of the specimen was confirmed to be an ectopic liver tissue without signs of malignant transformation. Discussion: Ectopic liver tissue is a rare congenital anomaly. It is defined as the presence of liver tissue outside the native liver. It occurs due to a failure of embryological liver development and it can be found in various organs of the body but the most common reported location is the gallbladder. Ectopic liver tissue is found to be functionally handicapped and more vulnerable to carcinogens and it is strongly associated with the development of hepatocellular carcinoma. Conclusion: Although it is a rare condition, ectopic liver tissue may pose a challenge to surgeons. When encountered, a surgical excision with histopathological examination is recommended because of its serious complications and the potential risk of malignant transformation.

A 6 yr old male Yorkshire terrier was presented for an ~6 yr history of progressive cough and dyspnea. Thoracic radiographs revealed a 6 cm diameter mass within the right caudal thorax. Thoracic ultrasound identified an intrathoracic mass ultrasonographically consistent with liver tissue and a chronic diaphragmatic hernia was suspected. Exploratory laparotomy was performed, but no evidence of a diaphragmatic hernia was identified. Thoracic exploration identified abnormal lung parenchyma. The accessory lung lobe was removed using a stapling devise near its base. The consolidated mass had the gross appearance of liver and was histologically identified as ectopic hepatic tissue. Ectopic hepatic tissue, unlike ectopic splenic and pancreatic tissue, is rare and generally has a subdiaphragmatic distribution. This solitary case report demonstrates that ectopic intrathoracic hepatic tissue should be considered a differential diagnosis for a caudal mediastinal mass.

Ectopic hepatic tissue presenting as right atrial mass

Ectopic liver is a rare congenital anomaly characterized by the presence of liver tissue outside the normal liver without any direct connection to it. These lesions are usually detected incidentally during clinical evaluation for other issues. However, they sometimes mimic neoplastic lesions both clinically and radiologically, which poses diagnostic challenges. Here, we present 5 patients with ectopic liver, 4 of which mimicked neoplastic lesions. The first was a 54-year-old woman diagnosed with multiple liver lesions and an enlarged gastro-hepatic lymph node, suspected to be a primary hepatic neoplasm with metastasis. Upon resection, it was found to be a hepatocellular adenoma in the liver and intraabdominal ectopic liver tissue with a small hepatocellular adenoma. Patient 2 was a 36-year-old woman presenting with palpitations and shortness of breath. An echocardiogram revealed a right atrial mass, which was identified as ectopic liver upon microscopic examination. The third patient was a 57-year-old woman with intermittent abdominal pain who underwent cholecystectomy. Microscopy revealed ectopic liver tissue on the gallbladder's serosal surface, along with chronic cholecystitis. The fourth was a 36-year-old woman with a gallbladder polyp, which on microscopy revealed ectopic liver tissue with no other abnormalities in the gallbladder. The fifth patient was a 57-year-old woman presenting with shortness of breath, weakness, and right atrial mass, which was confirmed as ectopic liver. These patients illustrate varied presentations of ectopic liver, sometimes mimicking neoplasia. Hepatocellular adenomas arising in ectopic liver and ectopic liver in intracardiac locations are extremely rare and can be a diagnostic pitfall, as they can clinically, radiologically, and pathologically mimic serious conditions like neoplasia.

IntroductionEctopic liver tissue is a rare entity, reported to occur in several intra-, retro- and extra- peritoneal sites, including the gallbladder. It is usually detected incidentally, during laparoscopy, laparotomy, or autopsy. Several possible mechanisms may explain the development of liver ectopia. Although ectopic liver tissue is usually asymptomatic, it behaves like orthotopic liver, developing the same pathologic conditions.Case presentationWe describe the case of a 54-year-old woman who was found to have a nodule attached to the gallbladder wall without any connection with the main liver, during an elective laparoscopic cholecystectomy for gallstone disease. The nodule was removed with the gallbladder and identified histologically as normal ectopic liver tissue.ConclusionIt would seem sensible to resect the ectopic tissue if encountered during cholecystectomy for gallstones. Laparoscopic management of ectopic liver can be feasible.

INTRODUCTION: Ectopic hepatic tissue (EHT) located in the posterior mediastinum is rare. The etiology of EHT is not well understood. We present a case of posterior mediastinal EHT causing mass effect in a middle-aged woman presenting with dysphagia. CASE DESCRIPTION/METHODS: A 50-year-old female presented to the ED with one year of intermittent dysphagia. Described as a “ball-like” sensation in the epigastrium. She denied abdominal pain, nausea, vomiting, hematemesis, early satiety, anorexia or weight loss. Her medical history was significant for peptic ulcer disease. She denied history of abdominal trauma or family history of malignancy. She was hemodynamically stable. Initial labs were nonrevealing. Physical exam was unremarkable. CT chest revealed a well-circumscribed posterior mediastinal mass measuring 3.9 × 3.4 × 3.2 cm. The mass was located to the right of the esophagus, homogeneous and measured 40 Hounsfield units. Her liver was noted to have a similar attenuation coefficient. Endoscopic evaluation revealed an area of mild extrinsic compression at the distal third of the esophagus (35 cm) which was easily traversed by the adult EGD scope. The Z line was seen at 36 cm from the incisors. The posterior mediastinal lesion was noted from 32 to 35 cm. It had an echogenic appearance of hepatic tissue and was noted to be continuous with the left lobe of the liver. This lesion was surrounded by a capsule with well-defined endosonographic borders. The mass was adjacent to the descending aorta and the ventricle. Mediastinal EHT was suspected to be the etiology of her symptoms. Fine needle biopsy was not performed due to proximity to the left ventricle. No other abnormalities were identified. A liver-spleen scan confirmed hepatic tissue in the posterior mediastinum. Outpatient evaluation with cardiothoracic surgery was planned. DISCUSSION: Although typically benign, ectopic hepatic tissue still warrants surgical evaluation and resection. Beyond exerting mass effect on surrounding structures, EHT may also undergo a malignant transformation to hepatocellular carcinoma (HCC). A review of recent medical literature disclosed many cases in which EHT preceded development of HCC, even when the remainder of the liver did not have HCC. Further studies are needed to determine the rate of malignant transformation.We urge consideration of EHT as a differential in the evaluation of posterior mediastinal masses. Given EHT’s propensity for malignant transformation, early recognition and close follow up is of vital importance.Figure 1.: CT Chest demonstrating posterior mediastinal mass continuous with the left lobe of the liver.Figure 2.: Mild extrinsic compression at the distal third of the esophagus approximately 35 cm from the incisors.Figure 3.: Ectopic Hepatic Tissue in the mediastinum.

Ectopic liver tissue represents a rare entity and is mostly attributed to events occurring during embryogenesis. Previous case reports documented the presence of fetal liver parenchyma within temporarily developed organs during pregnancy, such as the placenta or the umbilical cord. Moreover, the terminology of these benign findings varies from “ectopic liver” to “hepatocellular adenoma-like neoplasm” or “hepatocellular adenoma”. Ancillary tests performed on these lesions have shown positive immunohistochemical staining for hepatocellular origin marker HepPar-1. Only one recent case report comprising molecular analysis showed no beta-catenin gain-of-function mutation. We report a case of ectopic liver in one placenta of a twin pregnancy, with an updated review of literature.

Gallbladder-associated ectopic liver: A rare finding during a laparoscopic cholecystectomy

Introduction and importance: Ectopic liver tissue is a rare finding, often discovered incidentally during procedures like cholecystectomy. Understanding its clinical implications, including potential malignancy and complications, is crucial for effective management and improving patient outcomes. Case presentation: A 45-year-old female presented with six months of biliary colic, worsened by fatty meals. Preoperative ultrasound revealed a gallbladder with microcalculi. During elective laparoscopic cholecystectomy, a brownish tissue fragment resembling hepatic parenchyma was found on the gallbladder fundus and removed. Histopathology confirmed ectopic liver tissue with mild steatosis and no malignancy. Clinical discussion: Ectopic liver tissue, with a prevalence of 0.47%, typically attaches to the gallbladder but can also be found in other abdominal and thoracic locations. It may be linked to congenital malformations and has a risk of degeneration into malignancy due to its incomplete vascular and ductal system. Diagnosis is usually incidental during surgery, and en-bloc removal is advised to prevent complications and potential neoplastic transformation. Identifying its vascular supply before dissection is crucial to avoid severe bleeding. Conclusion: Ectopic liver tissue, despite its rarity, requires careful management due to its potential for malignancy and complications. Timely detection and en-bloc removal are vital to prevent adverse outcomes and ensure optimal patient care.