Electronic Clinical Challenges and Images in GI

Abstract

Question: A 45-year-old woman presented with acute right upper abdominal pain, diaphoresis, and nausea. Physical examination revealed abdominal guarding and a palpable mass below the right costal arch. No fever or change in bowel movements was present. Her only medication was oral contraception. The patient had had similar attacks of abdominal pain several times before, which resolved spontaneously. Laboratory exam revealed slightly elevated liver enzymes (aspartate aminotransferase, 67 U/L [normal range, 35]; alanine aminotransferase, 95 U/L [normal ange, 34]), and normal complete blood count, bilirubin, and lipase; no anemia was present. Abdominal contrast-enhanced computer omography (CT) showed an encapsulated, hypodense, hypoperfused mass (10 15 cm) below the liver (Figure A, B, white arrows) with the allbladder situated posteriorly from the tumor (Figure A , C, long black arrow). At the liver/tumor interface in segment V close to the liver hilum, helical formation of arteries (“swirl sign”) was seen, fed by the cystic artery and branches arising from the segment V of the liver (Figure C, white mall arrow). Nearby, another well-perfused, small tumor was present (Figure C, small black arrow). After receiving pain medication, her symptoms esolved, and abdominal magnetic resonance imaging (MRI) of the upper abdomen was performed on the same day with hepatocyte-specific ontrast material (gadoxetic acid; Primovist or Eovist; Bayer Schering Pharma) to further characterize the hepatic masses. In contrast to CT, there as a multinodular hyperperfusion without a “swirl” of arteries. During the hepatobiliary phase, both masses did not demonstrate specific epatocellular contrast accumulation (Figure D–F; white arrows and small black arrow). This time, the gallbladder was located anteriorly and showed ontrast filling in the hepatobiliary phase proving the patency of the cystic duct (Figure F, long black arrow). What is the most likely diagnosis? See the GASTROENTEROLOGY web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI.