Indeterminate Liver Research Articles

The value of preoperative computed tomography combined with ultrasound in the investigation of small indeterminate liver lesions in patients with colorectal cancer.

Background Computed tomography (CT) is used routinely for the preoperative detection of colorectal cancer (CRC) metastases. When small indeterminate focal liver lesions are detected that are too small to characterize (TSTC) on CT, additional imaging is usually needed, resulting in a potential delay in obtaining a complete diagnostic work-up. Purpose To determine the diagnostic accuracy of ultrasound (US) of the liver performed in direct conjunction to CT in the preoperative investigation among patients with newly diagnosed CRC when indeterminate liver lesions were found on CT. Material and Methods Preoperative investigations with CT and consecutive US where CT had shown at least one focal liver lesion in 74 patients diagnosed with CRC between June 2009 and February 2012 were retrospectively reviewed. Either histopathological findings or a combination of imaging and clinical follow-up one to three years after surgery was used as the reference. Results Liver metastases were diagnosed with CT/US in 13 out of 74 patients (17.6%). In one patient, a liver cyst was preoperatively regarded as liver metastasis by a combined CT/US. The sensitivity and specificity for the CT with consecutive US procedure was 100% (13/13) and 98.4% (60/61). Conclusion US performed in conjunction with CT in patients with indeterminate focal liver lesions on CT is an accurate work-up for detection of liver metastases in patients with newly diagnosed CRC. Although our results are promising, they cannot be considered safely generalizable to all hospitals.

The Management of Patients with Colorectal Cancer and Synchronous Liver Metastases or Indeterminate Liver Lesions: A Community Teaching Hospital Experience

The Management of Patients with Colorectal Cancer and Synchronous Liver Metastases or Indeterminate Liver Lesions: A Community Teaching Hospital Experience

Low vitamin D status is associated with advanced liver fibrosis in patients with nonalcoholic fatty liver disease.

Several studies explored the association between vitamin D status and nonalcoholic fatty liver disease with contradictory results. We aimed to investigate the association between vitamin D status, inflammatory cytokines and liver fibrosis in nonalcoholic fatty liver disease patients. Two hundred nineteen nonalcoholic fatty liver disease patients and 166 age- and gender- matched healthy controls were recruited for this study. Serum 25(OH)D was measured by radioimmunoassay. Serum interleukin-8 and transforming growth factor-β1 were measured using ELISA. Serum 25(OH)D was only marginally decreased in nonalcoholic fatty liver disease patients. Interestingly, serum 25(OH)D was markedly reduced in nonalcoholic fatty liver disease patients with advanced liver fibrosis compared to nonalcoholic fatty liver disease patients with indeterminate liver fibrosis and no advanced fibrosis. Logistic regression analysis showed that there was an inverse association between serum 25(OH)D and severity of liver fibrosis in nonalcoholic fatty liver disease patients. Further analysis showed that serum interleukin-8 was elevated in nonalcoholic fatty liver disease patients, the highest interleukin-8 in patients with advanced fibrosis. An inverse correlation between serum 25(OH)D and interleukin-8 was observed in nonalcoholic fatty liver disease patients with and without liver fibrosis. Although serum transforming growth factor-β1 was slightly elevated in nonalcoholic fatty liver disease patients, serum transforming growth factor-β1 was reduced in nonalcoholic fatty liver disease patients with advanced fibrosis. Unexpectedly, a positive correlation between serum 25(OH)D and transforming growth factor-β1 was observed in nonalcoholic fatty liver disease patients with advanced fibrosis. In conclusion, low vitamin D status is associated with advanced liver fibrosis in nonalcoholic fatty liver disease patients. Interleukin-8 may be an important mediator for hepatic fibrosis in nonalcoholic fatty liver disease patients with low vitamin D status.

PTH-103 Evaluation of a novel system for image guided laparoscopic liver surgery in an animal model and first clinical experience

PTH-103 Evaluation of a novel system for image guided laparoscopic liver surgery in an animal model and first clinical experience

Phase II study of preoperation mFOLFIRINOX and chemoradiation for high-risk resectable and borderline resectable pancreatic adenocarcinoma.

362 Background: Patients with high risk resectable and borderline resectable pancreatic adenocarcinoma (BRPC) are at a high risk for R1/R2 resection, early relapse with upfront surgery and poor OS. Preop therapy has a sound rationale and current retrospective data suggest resection rates of 40-60% with a possible impact on OS. Methods: We planned a prospective study of 33 pts. Eligibility includes diagnosis of pancreatic ductal carcinoma (PC) and >=1 criteria of BRPC (radiographic) A: (i) PC involves SMV with vein deformity or segmental occlusion; (ii) PC involves <=1800 SMA, CA or its branches (iii) abutment or encased short segment of CHA and/or BRPC (high-risk) B: (iv) CA19-9 >=500 mg/dl (v) malignant peripancreatic nodes outside planned surgical field (vi) indeterminate liver or peritoneal lesions. Enrolled pts receive mFOLFIRINOX (oxaliplatin 75 mg/m2 d1+ irinotecan 150 mg/m2 d1+ 5-FU 2000mg/m2 46h CI) for 6 cycles. Those without progression & good PS undergo EBRT 50.4Gy with weekly Gemcitabine 350 mg/m2. Surgery is planned 4-6 weeks after CRT in pts without progression. Results: 24/33 pts accrued. 18(75%) with A criteria alone; 1(4%) with B criteria alone and 5 (21%) with both. Median age is 66 yrs; ECOG PS0 42%, PS1 58%. Median CA19-9 is 219 (1-1185) mg/dl. 20/24 have completed all preop therapy and 10 underwent surgery (50%).10 patients did not proceed to surgery due to disease progression (5), poor PS (3) or withdrawal of consent (2). Grade ¾ hematologic and non-hematologic toxicity noted in 8/21 (38%). Of the 10 resected pts, all underwent vein reconstruction and R0 rate is 80%. Major pathologic response rate (>50 % tumor kill) was 30%. One (bleeding) major complication occurred within 90 d of surgery. 5/10 resected pts relapsed <1yr after surgery with a median TTP from surgery of 5mo (3-7mo). SMAD4 and CTC analysis pending. Conclusions: Although the sample size is limited, using strict criteria, resection rates with preop FOLFIRINOX and Gem-RT mirror retrospective data (50%). Half of the resected pts have recurred early suggesting aggressive preop therapy does not rescue aggressive biology. Further analysis may allow identification of pts who are poor candidates for an aggressive preop approach. Clinical trial information: NCT01560949.

Outcome of ultrasound guided pigtail catheter drainage of liver abscesses a prospective study of 126 cases

Background: With the advances in the intervention radiological techniques the laparotomy for liver abscess has been taken over by the percutaneous ultrasound guided needle aspiration as well as percutaneous ultrasound guided pigtail catheter drainage. This study was undertaken at Govt. Medical College & Associated hospitals, Jammu to assess the outcome of this minimally invasive procedure for Liver abscess. Methods: 126 patients were subjected to pigtail catheter drainage after localization with ultrasonography using modified Seldinger’s technique. The pigtail catheters of 8-14 Fr size was were used. All the samples of pus were subjected to microscopy for EH trophozoites, Gram stain and for pus culture and sensitivity. Patient’s vitals were monitored for 24 hours. Daily estimation of volume, colour and consistency of the drainage fluid was recorded. Follow-up USG was done on average of 5th postoperative day to assess the shrinkage of cavity and the amount of residual fluid. Removal of catheter was decided based on; the amount of pus drained (<50 ml for three consecutive days); disappearance of symptoms & signs; and USG abdomen showing signs of resolution. Results: The age of the patients in this study ranged from the 21 years to 70 years with M: F ratio of 13.5: 1. Pain, fever, tender hepatomegaly & anaemia were common symptomatology. Right lobe abscess was seen in 74.60% (n=94) of patients. Solitary abscess was seen in 110 patients (87.3%). 66 patients (52.38%) had ALA, 18 patients PLA & 42 were having indeterminate liver abscess. Smaller size catheter specially 8-10 Fr invariably blocks. Common problems encountered were local pain or discomfort due to catheter, peri-tubal leak in few cases, and local wound infection. The average period of continuous catheter drainage was 7.2 days maximum being 26 days. Average duration of hospital stay was 2.45 days. Success rate of the procedure was 96.82% (n=122). 04 patients needed laparotomy. Conclusions: Advances in interventional radiology have influenced management of liver abscess. We in our series of 126 pts of liver abscess conclude that image guided percutaneous pigtail drainage of liver abscess is a safe, effective minimally invasive procedure with negligible morbidity and no mortality. High procedural success rate has almost replaced conventional laparotomy in uncomplicated liver abscess.

Tu1618 Roux-en-Y Drainage of the Pancreatic Stump by Nonstented Duct-to-Mucosa Anastomosis Reduced the Amylase Level in the Drainage Fluid After Distal Pancreatectomy With En-bloc Celiac Axis Resection

Background: Pancreatic cancer is one of the leading causes of cancer mortality. Surgery is the only chance of cure, but is inappropriate for patients with metastasis. Aim: To evaluate the frequency of liver metastasis on MRI in patients with resectable pancreatic cancer and normal liver on contrast enhanced MDCT. Methods: Between April 2012-13, all patients with resectable pancreatic cancer based on CT staging underwent MRI liver utilising hepatocyte specific contrast agent and diffusion weight imaging. Results: Forty five consecutive patients were examined. Thirty two were male and 13 were female. Median age was 64 years (range 31-76 years). MRI was performed at a median of 2 weeks from CT. Thirteen (29%) patients with normal liver on CT had findings consistent with liver metastases while 4 (9%) had indeterminate liver lesions on MRI. Three of the 4 patients with indeterminate liver lesions demonstrated progression on follow up imaging consistent with metastases. One of the 28 patients with a normal MRI liver underwent palliative bypass on discovering a 5mm subcapsular lesion at laparotomy. At a median follow up of 12 months, 3 of the remaining 27 patients with normal MRI had evidence of liver metastasis (7, 10 and13 months post MRI) while 4 had extrahepatic disease. Survival was significantly reduced in patients with liver metastasis on MRI (p=0.01). Conclusion: MRI identified liver metastases in 36% of patients with resectable pancreatic cancer on MDCT and should be included in the routine staging of these patients.

Experience of laparoscopic liver resection for various liver diseases.

Backgrounds/AimsWe present our experience of laparoscopic liver resection for various liver diseases.MethodsFrom April 2008 to August 2012 in Chungnam National University, 68 of 253 liver resections were performed laparoscopically. During the first year, laparoscopy-assisted liver resection was mainly performed and subsequently totally laparoscopic liver resection was the main operative type. Surgery type for treatment purposes was decided preoperatively. Clinical data were collected retrospectively and analyzed.ResultsPreoperatively, 43 patients (63.2%) were diagnosed with benign disease, 19 patients (27.9%) were malignant liver tumors and 6 patients (8.8%) were indeterminate liver tumor but favorable towards malignancy. Anatomical major liver resection was performed in 58 cases (85.3%) and 10 cases (14.7%) were non-anatomical resection. Left hemihepatectomy was performed in 38 cases (55.8%) followed by left lateral sectionectomy in 18 cases (26.5%), and segment IV and IVa segmentectomy, were each in 1 case. Mean operation time was 235.0 minutes (range, 60-470) and 14 patients (18.6%) had intraoperative transfusion. Mean postoperative hospital stay was 10.2 days (range, 4-32). Mean operation time of laparoscopy-assisted left lobectomy was 317 minutes and totally laparoscopic left lobectomy was 281 minutes, but there was no significant statistical difference between these two operation types. There were 11 episodes of postoperative complications in 8 patients. There was no mortality after laparoscopic liver resection.ConclusionsWe concluded that laparoscopic liver resection is a feasible operation, but needs to be carefully conducted in malignant tumors.

A Retrieval-Based Computer-Aided Diagnosis System for the Characterization of Liver Lesions in CT Scans

To evaluate a computer-aided diagnosis (CADx) system for the characterization of liver lesions in computed tomography (CT) scans. The stand-alone predictive performance of the CADx system was assessed and compared to that of three radiologists who were provided with the same amount of image information to which the CADx system had access. The CADx system operates as an image search engine exploiting texture analysis of liver lesion image data for the lesion in question and lesions from a database. A region of interest drawn around an indeterminate liver lesion is used as input query. The CADx system retrieves lesions of similar histology (benign/malignant), density (hypodense/hyperdense), or type (cyst/hemangioma/metastasis). The system's performance was evaluated with leave-one-patient-out receiver operating characteristic area under the curve on 685 CT scans from 372 patients that contained 2325 liver lesions (193 <1 cm(3)). Sensitivity, specificity, and positive and negative predictive values were evaluated separately for subcentimeter lesions. Results were compared to those of three radiologists who rated 83 liver lesions (20 hemangiomas, 20 metastases, 20 cysts, 20 hepatocellular carcinomas, and 3 focal nodular hyperplasias) displaying only the liver. The CADx system's leave-one-patient-out receiver operating characteristic area under the curve was 97.1% for density, 91.4% for histology, and 95.5% for lesion type. For subcentimeter lesions, input of additional semantic information improved the system's performance. The CADx system has been proved to significantly outperform radiologists in discriminating lesion histology and type, provided the radiologists have no access to information other than the image. The radiologists were most reliable in diagnosing hemangioma given the limited image data. The CADx system under study discriminated reliably between various liver lesions, even outperforming radiologists when accessing the same image information and demonstrated promising performance in classifying subcentimeter lesions in particular.

Hepatic contrast-enhanced ultrasound: Impact of its introduction in the Australian context

Contrast-enhanced ultrasound (CEUS) is a relatively new imaging modality in Australia. We discuss our early experience with CEUS at Royal Melbourne Hospital in assessment of focal liver lesions and its clinical impact. Radiology department and hospital computerised information systems were used to identify and collate information regarding the indication, previous and follow-up imaging, CEUS findings and subsequent final diagnoses of patients who underwent hepatic CEUS from 12/12/2007 to 20/4/2012. A total of 388 hepatic CEUS were performed, examining 409 lesions. The cases were grouped as either 'initial study' or 'follow-up' group, with main focus on the former group. Of the 367 lesions in the 'initial study' group, CEUS was able to distinguish benign from malignant pathology in 344 cases (93.8%). This was especially beneficial in setting of known malignancy with indeterminate liver lesions found on CT to confidently exclude metastatic disease. For 124 of 162 patients who had an incidentally detected indeterminate liver lesion, CEUS was the final imaging investigation required to make a diagnosis. CEUS is a valuable tool in assessment of focal liver lesions in conjunction with other conventional modalities in a variety of clinical settings. In particular, it provided definitive diagnosis in a significant proportion of incidentally identified liver lesions many of which are benign, saving patient anxiety and further unnecessary follow-up.

Indeterminate Liver and Renal Lesions

The purpose of this study was to compare computed tomography (CT) and magnetic resonance imaging (MRI) in terms of likelihood of providing a definitive diagnosis (DD) and a recommendation for additional imaging (RAI), when performed to evaluate indeterminate liver and renal lesions detected on ultrasound as well as in terms of impact on imaging costs. This retrospective study was Health Insurance Portability an Accountability Act (HIPAA)-compliant and institutional review board-approved, with waiver of informed consent. We identified consecutive indeterminate liver and renal lesions detected on ultrasound that underwent contrast-enhanced CT or MRI for further characterization. Reports from follow-up studies were reviewed for whether the impression provided DD and RAI. Frequency of DD and RAI was compared between CT and MRI using the Fisher exact test. On the basis of the observed frequency of DD, anticipated imaging costs were compared in a hypothetical sample of 100 patients with indeterminate lesions between first obtaining multiphase CT for all lesions and a subsequent MRI for those lesions indeterminate on CT versus directly obtaining a multiphase MRI for all lesions. A total of 143 renal lesions were included, of which 77 and 66 underwent CT and MRI, respectively. Magnetic resonance imaging was significantly more likely than CT to provide DD (95.5% vs 77.9%; P = 0.003) and significantly less likely to provide RAI (1.5% vs 10.4%; P = 0.038). A total of 221 liver lesions were included, of which 76 and 145 underwent CT and MRI, respectively. Magnetic resonance imaging was significantly more likely than CT to provide DD (95.2% vs 71.1%; P < 0.001) and significantly less likely to provide RAI (0% vs 10.5%; P < 0.001). Across the entire study cohort, there were 13 instances of MRI recommended after an indeterminate CT and 1 case of CT recommended after an indeterminate MRI. A DD was provided in 8 of 9 instances in which MRI was performed after an indeterminate CT. However, anticipated imaging costs were higher when directly obtaining MRI for all indeterminate lesions, compared with initially obtaining multiphase CT, for both kidney ($64,739 vs $49,759) and liver ($64,739 vs. $56,975) lesions, respectively. For indeterminate liver and renal lesions detected on ultrasound, MRI is more likely to provide DD and less likely to provide RAI in comparison with CT, although these differences did not result in lower anticipated imaging costs.

Prevalence and significance of subcentimeter hepatic lesions in patients with localized pancreatic adenocarcinoma

PurposeTo determine the prevalence and significance of incidental, subcentimeter hepatic lesions in patients with a new diagnosis of pancreatic cancer. Materials and MethodsThis Institutional Review Board-approved retrospective study included 101 patients [45% men, median age 63 years (34-85)] treated for localized pancreatic adenocarcinoma at Brigham and Women's Hospital and Dana Farber Cancer Institute from January 1999 to December 2007. Initial staging and follow-up computed tomographic scans were reviewed to determine the frequency of liver lesions that were initially too small to characterize and later proved to be metastases. Clinical variables known to be prognostic for patients with pancreatic cancer were also recorded. Using Cox regression, we calculated adjusted hazard ratios to determine the association between presence of liver lesions and overall survival. ResultsA total of 31 patients (30.7%) had subcentimeter hepatic lesions on staging scans. Of these patients, 21 (20.7% of total, 67.7% of patients with lesions) had eventual metastases to the liver. Finally, of this group, 5 patients (5.0% of total, 16.1% of patients with lesions) eventually had a metastatic focus at the specific site of the original lesion. Liver lesions predicted the occurrence of metastatic disease to the liver compared with patients without lesions (67.7% with lesions vs 44.4% without, P = .034). The presence of subcentimeter liver lesions at diagnosis was significantly associated with reduced overall survival (hazard ratio 1.65; 95% confidence interval 1.03-2.64, P = .036). ConclusionsSubcentimeter lesions in the liver are common in patients with a new diagnosis of pancreatic cancer. Approximately 16% of these lesions represent metastases. The presence of indeterminate liver lesions may be associated with reduced overall survival.

Hepatocellular Carcinoma Presenting at Contrast-Enhanced Multi–Detector-Row Computed Tomography or Gadolinium-Enhanced Magnetic Resonance Imaging as a Small (≤2 cm), Indeterminate Nodule

The objective of the study was to measure growth rate and to determine the optimal interval time for imaging follow-up of hepatocellular carcinomas (HCCs) presenting at multi-detector-row computed tomography (MDCT) or magnetic resonance imaging (MRI) as small, indeterminate lesions. We included patients with cirrhosis with HCC initially presenting as indeterminate lesion of 2 cm or less at MDCT or MRI August 2005 to August 2009 and with available imaging follow-up. Measures of tumor growth included tumor volume doubling time (TVDT), tumor percentual diameter increase, and tumor percentual volume increase. We examined 48 patients (mean age, 64 years) with 69 HCCs. At index examination, mean (SD) maximum transverse diameter and volume of lesions were 1.2 (SD, 0.3) cm and 0.6 (SD, 0.7) cm, respectively. Median TVDT was 210 days. Tumors with follow-up longer than 365 days had significant increase in tumor percentual diameter increase and tumor percentual volume increase. Median TVDT of 210 days suggests extended follow-up of 6 months for small, indeterminate liver nodules detected at MDCT or MRI.

Detection of acetaminophen–cysteine adducts in cases of indeterminate liver failure is not diagnostic of intentional overdose

Detection of acetaminophen–cysteine adducts in cases of indeterminate liver failure is not diagnostic of intentional overdose

Surgical Management of Benign and Indeterminate Hepatic Lesions in the Era of Laparoscopic Liver Surgery

Background/Aims: The expansion of the laparoscopic approach for the management of benign liver lesions has raised concerns regarding the risk of widening surgical indications and compromising safety. Large single-centre series focusing on laparoscopic management of benign liver lesions are sporadic. Methods: We reviewed a prospectively collected database of patients undergoing pure laparoscopic liver resection (LLR) for benign liver lesions. All cases were individually discussed at a multidisciplinary team meeting. Results: Forty-six patients underwent 50 LLRs for benign disease. Indications for surgery were: symptomatic lesions, preoperative diagnosis of adenoma or cystadenoma, and lesions with an indeterminate diagnosis. The preoperative diagnosis was uncertain in 11 cases. Of these, histological diagnosis was hepatocellular carcinoma in one (9%) and benign lesion in 10 patients (91%). Thirteen patients (28%) required major hepatectomy. Three patients (7%) developed postoperative complications. Mortality was nil. The median postoperative hospital stay following major and minor hepatectomy was 4 and 3 days, respectively. Conclusion: The laparoscopic approach represents a safe option for the management of benign and indeterminate liver lesions, even when major hepatectomy is required. LLR should be only performed in specialized centres to ensure safety and strict adherence to orthodox surgical indication.

Real-Time Ultrasonography-Computed Tomography Fusion Imaging for Staging of Hepatic Metastatic Involvement in Patients With Colorectal Cancer

To prospectively evaluate the role of real-time ultrasonography (US)-computed tomography (CT) fusion imaging (US-CT) in comparison with US seeing separate CT images (US + CT) and multidetector-row CT (MDCT) for the correct staging of hepatic metastatic involvement in patients with colorectal cancer. Sixty-four patients with newly diagnosed colorectal cancer and who were referred for abdominopelvic staging before primary tumor resection underwent same-day MDCT, US + CT, and US-CT. Examinations were evaluated on-site by 2 investigators in consensus. Investigators recorded the size and location of detected lesions on segmental liver maps, classified them as being benign, malignant, or indeterminate, and finally assessed the M stage of the liver as being M0, M1, or Mx (indeterminate). All patients underwent surgical exploration including intraoperative US. Reference standard diagnosis was based on findings at surgery, intraoperative US, histopathology, and MDCT follow-up imaging. Differences among investigated modalities were analyzed using McNemar's test. The reference standard verified 109 (45 < or = 1 cm) hepatic lesions in 25 patients, including 65 (25 < or = 1 cm) metastases in 16 patients (M1). Regarding the 45 < or = 1 cm liver lesions, rates for detection were significantly higher (P < 0.05) for MDCT (80%, 36/45) and US-CT (77.8%, 35/45) than for US + CT (64.4%, 29/45); the rate for correct classification by US-CT (71.1%, 32/45) was significantly higher than for US + CT (48.9%, 22/45) and MDCT (31.1%, 14/45) (all P < 0.05). On patient-based analysis, specificity of MDCT (85.4%, 41/48) was significantly lower (P < 0.05) than for US-CT (97.9%, 47/48) and US + CT (93.7%, 45/48); the positive predictive value of MDCT (63.1%, 12/19) was not significantly different (P = 0.27) compared with US + CT (82.3%, 14/17) but significantly lower (P < 0.05) than for US-CT (93.7%, 15/16). In 13 patients (59 lesions) with only benign (stage M0) or coexistent benign and malignant lesions (stage M1), indeterminate lesion ratings and indeterminate liver stagings (Mx) occurred both significantly lower (P < 0.05) with US-CT (3.4%, 2/59; and 0%, 0/13) than with US + CT (11.9%, 7/59; and 23.1%, 3/13) or with MDCT (30.5%, 18/59; and 53.8%, 7/13). Based on these initial diagnostic experiences, complementary US-CT fusion imaging of small CT-indeterminate liver lesions may have value in staging patients with colorectal cancer, focusing on patients who were likely to harbor only benign or coexisting benign and malignant liver lesions and in whom change of M staging would change the clinical management.

Natural History of Small, “Indeterminate” Hepatic Lesions in Patients with Colorectal Cancer

The initial staging CT scan for patients with colorectal cancer may reveal small, "indeterminate" hepatic lesions. The significance of these lesions is often unknown at the time of diagnosis. Surveillance of these lesions is often recommended because they may have an impact on the subsequent management of these patients. This study was designed to determine the prevalence and significance of small (<1 cm on CT scan), indeterminate liver lesions detected preoperatively in patients with colorectal cancer and to determine whether further surveillance imaging of these patients is required. Data were collected retrospectively, from January 1, 2002, to December 31, 2005. All colorectal cancer patients with small, indeterminate liver lesions on their initial staging CT scan were included. These lesions were formally reported as being too small to be characterized. All subsequent surveillance images of the liver were reviewed to assess the natural history of these lesions. Four hundred nineteen patients with colorectal cancer had staging CT performed. Seventy patients (16.7%) had small liver lesions on their initial CT that could not be definitely characterized. Forty-six (65.7%) underwent subsequent imaging of their liver lesions. Forty-one (89.1%) of these were shown to be stable lesions that were likely benign. Only five patients (10.9%) showed progression on subsequent liver imaging, suggestive of early metastases and consistent with their clinical picture. Small, indeterminate liver lesions may occur in up to 16.7% of patients with colorectal cancer. Although most of these lesions remain quiescent, surveillance imaging is recommended because a small but not insignificant proportion of patients with such lesions actually harbor early metastases.

Clinical Relevance of Transjugular Liver Biopsy in Comparison with Percutaneous and Laparoscopic Liver Biopsy

Background. Transjugular liver biopsy (TJLB) is frequently used to obtain liver specimens in high-risk patients. However, TJLB sample size possibly limits their clinical relevance. Methods. 102 patients that underwent TJLB were included. Clinical parameters and outcome of TJLB were analyzed. Control samples consisted of 112 minilaparoscopic liver biopsies (mLLBs) and 100 percutaneous liver biopsies (PLBs). Results. Fewer portal tracts were detected in TJLB (4.3 ± 0.3) in comparison with PLB (11.7 ± 0.5) and mLLB (11.0 ± 0.6). No difference regarding the specification of indeterminate liver disease and staging/grading of chronic hepatitis was observed. In acute liver failure (n = 32), a proportion of hepatocellular necrosis beyond 25% was associated with a higher rate of death or liver transplantation. Conclusions. Despite smaller biopsy samples the impact on the clinical decision process was found to be comparable to PLB and mLLB. TJLB represents a helpful tool to determine hepatocellular necrosis rates in patients with acute liver failure.

Prognostic Implications of Lactate, Bilirubin, and Etiology in German Patients With Acute Liver Failure

Among the potentially helpful indicators of poor prognosis in acute liver failure (ALF) are etiology, encephalopathy grade, blood lactate, and King's College Criteria (KCC). The accuracy of these parameters in predicting transplantation or death shows significant variation in different countries. We retrospectively analyzed 102 patients with ALF treated at our institution between 1996 and 2005. Baseline parameters, simplified acute physiology score III (SAPS-III), KCC, Model for End-Stage Liver Disease (MELD) score, and a novel score of bilirubin, lactate, and etiology (BiLE score) were compared between transplant-free survivors and patients who required liver transplantation or died, by using multivariate linear regression analysis and receiver operating characteristics (ROC). The most common causes of ALF were indeterminate liver failure (21%), acute hepatitis B (18%), acetaminophen ingestion (16%), and Budd-Chiari syndrome (9%). Transplantation-free survival was 38%, 44% of patients underwent liver transplantation, and 18% died without transplantation. Eight-week survival was 77%. The BiLE score was the best predictor of death or need of transplantation, with 79% sensitivity and 84% specificity. ROC analysis revealed a better performance of BiLE score when compared with bilirubin, lactate, MELD score, and SAPS-III (area under the curve: 0.87 +/- 0.04, 0.73 +/- 0.51, 0.73 +/- 0.52, 0.71 +/- 0.05, and 0.68 +/- 0.59, respectively). The simple, combined BiLE score emerged as the best predictor of poor outcome in our patient cohort and should be prospectively evaluated in other populations.

A 2-year-old Boy with Fever and Altered Mental Status

&lt;P&gt;This 2-year-old boy was admitted to the intensive care unit for evaluation of fever and altered mental status. He was well until 3 days prior to admission, when he developed temperature of 103° F and abdominal pain. Two days prior to admission, he developed a progressively worsening cough, watery, non-bloody diarrhea, and non-bilious emesis. On the day of admission, he was wobbly when sitting on the toilet and unable to walk. Review of systems was unremarkable. His past medical history was remarkable for moderate persistent asthma and two prior intensive care unit admissions, which required endotracheal intubation. He had had several simple febrile seizures. Medications at home included inhaled albuterol and budesonide. During this illness, he had also received alternating doses of acetaminophen and ibuprofen. His development was age-appropriate.&lt;/P&gt;&lt;H4&gt;Key Learning Points&lt;/H4&gt;&lt;OL&gt; &lt;LI&gt;The definition of fulminant liver failure is the presence of liver synthetic dysfunction (INR &gt; 2) and encephalopathy within 6 to 8 weeks of any evidence of liver disease. &lt;/LI&gt;&lt;LI&gt;Sick, fasting children should not be given more than four 15 mg/kg doses of acetaminophen in a 24-hour period. There’s evidence to suggest that some children who have indeterminate liver disease actually have acetaminophen-induced liver injury.&lt;/LI&gt;&lt;LI&gt;If a child is on specific antimicrobial or antiviral therapy, the co-administration of corticosteroids is generally safe from the infectious disease perspective.&lt;/LI&gt;&lt;LI&gt;Acute necrotizing encephalopathy (ANE) has been associated primarily with influenza infection and is characterized by fever, vomiting, seizures and lethargy, and rapid progression to coma. The characteristic neuroradiologic findings are hypodense lesions on computerized tomography (CT) scan, hypointensities on T2-weighted magnetic resonance imaging (MRI) scan in bilateral thalami, as well as lesions in the internal capsule, brainstem tegmentum, and cerebellar medulla. &lt;/LI&gt;&lt;/OL&gt;&lt;H4&gt;ABOUT THE AUTHOR&lt;/H4&gt;&lt;P&gt;Dr. Listernick is Professor of Pediatrics at Feinberg School of Medicine, Northwestern University, and Director of the Diagnostic and Consultation Service, Division of General Academic Pediatrics, Children’s Memorial Hospital, Chicago, IL.&lt;/P&gt;