A case of severe abdominal right upper quadrant pain in a patient on ASS and Clopidogrel

Abstract

Purpose: We describe the case of a 73 year old patient with a large subhepatic mass and two hepatic lesions found on external US. The patient had no known liver disease and was on dual platelet inhibition for a DES that had been implanted 4 months prior. Material and methods: We performed US, CEUS, MRI and liver histology Results: US raised suspicion of a HCC in SII (24 ml) and a second HCC in SV (16 ml) with a big subhepatic hematoma after spontaneous bleeding. (When asked, the patient reported severe RUQ pain 2 weeks before.) There were no obvious signs of cirrhosis. CEUS of the lesion in SII was suggestive of HCC. The second lesion showed ring enhancement in the arterial phase with the ring opening to the large subhepatic mass. The rest of the lesion and the subhepatic mass took up no contrast at all, consistent with intralesional and subhepatic hematoma. MRI was interpreted as possible, but not typical HCC. It confirmed intralesional and subhepatic hematoma. AFP was negative as were Hep B and C-Serologies. In view of the discordant results, biopsy was planned. The treating cardiologists however advised against stopping dual platelet inhibition. Follow-up six weeks later showed a marked enlargement of the lesion in SII, whose volume almost tripled (70 ml), whereas the lesion in SV had regressed (5 ml). Repeat-CEUS was again suggestive of HCC. Because of the rapid growth, uneventful biopsy was undertaken after cardiologists' approval and stopping of clopidogrel with the patient still taking ASS. Histology confirmed HCC (G2) with a Ki Index of 30%. It also showed marked liver fibrosis. Conclusion: Careful History, US and CEUS solve most mysteries. The experienced sonographer should trust his judgement. A bleeding liver tumor in an elderly person is most probably a HCC.