CPC 87/4/11 Shariati hospital- Shahid Peyroviani hall

PP: 69 year-old man   reside in Tehran   diploma   retired employee of Mokhaberat

PI: The patient is a 69 year-old man during evaluation of his inguinal hernia using MRI in year 1382, a mass was accidentally found in his lever. The mass was about 2 cm in diameter in the lateral of left lobe and further evaluations revealed hemangioma. His liver mass was gradually enlarged from 2cm up to 15cm since 1382 to 1387. He has lost his weight about 8kg during this period but the majority has occurred most recently. The patient has involved in two episodes of fever, chills severe sweating, malaise and nausea at 1385/12 and 86/12. He did not have abdominal pain or pruritus. His fever responds to oral or IV antibiotics hardly and with delay.

PMH: HTN, BPH. NO other medical diseases such as DM, IHD or GI diseases

PSH (1384): Hernioplasty, herniorrhaphy, hydrocelectomy Biopsy: Pachyvaginitis Phlebosclerosis ectatic (varicocele)

DH: amlodipine (daily), atenolol (25mg/d), prazocin (1mg at bedtime), alprazolam He has not consumed any other chemical or herbal drugs.

FH: negative

SH: up to 12 he used to live in Rasht and then came to Tehran. He is retired employee of Mokhaberat. He used to be a wrestler or coach and has been smoker for 15 years (4 P/Y) but he stopped smoking 8 years ago. No alcohol consumption. No opium addict.

PHE: BP=130/80   PR=70   RR=14   T=36.8 oral    Conjunctiva was not pale or icteric. Sclera was not icteric. Head and neck was not remarkable and no lymphadenopathies were palpated. Auscultation of heart and lungs were NL. The scar of abdomen was seen in midline and RUQ and RLQ. The abdomen was flat and no flanks bulging. Liver and spleen were not palpated. No shifting dullness. No mass. No tenderness. No leg edema. Peripheral pulses were normal and symmetric.

LAB EXAM:

WBC=6600   Hb=14.6   MCV=85   PLT=184000 Neutr=63%  lymph=30%  mono=4%  eos=3%

86/5/24 → AST=26  ALT=21  ALP=104  LDH=145  BIL(T)=0.9 BIL(D)=0.2  GGT=62 (NL<49)

87/1 →AST=350  ALT=105  ALP=358  BIL(T)=2.1  BIL(D)=0.3 PT=13  INR=1  PTT=30  BUN= 15  CR=1  FBS=101  ESR=84 CRP=less than 2 mg/l (NL<10)   Total protein=6.9   alb=4.2   A/G ratio=1.6  Iron=84  TIBC=274  Ferritin= 320  TG=70 Cholesterol=131 

U/A: WBC=3-4 RBC=14-16 Bacteria=none other=NL 

S/E: negative for fat, undigested food, OB, yeast, WBC, RBC, ova of parasites, protozoa cyst

Total PSA=0.3  T3=1.7  T4=8.7 TSH=0.2  Wright and Widal= negative   Viral markers= negative 

87/1  Fasiolla hepatica=0.1 U (Neg<0.3) 

84/12/16 → AFP=1.6 U/ml 

87/3/13 → AFP=6.52 U/ml BHCG=0.3 mlU CEA=2.1 ng/ml (NL<3.4 in nonsmoker) CA19-9=11 (NL<39) CA15-3=18 (NL<25)

IMAGING

Abdominopelvic Sonography (82/11/19): liver is NL size. A hyperecho region with 2.2*2cm is seen in the lateral of the left lobe of the liver that seems a hemangioma. Others NL.

MRI (82/11): a 2cm nodule is seen in the center of the liver between right and left hepatic lobes. The lesion is high on T2w and low in T1w with respect liver parenchyma and most likely represents hemangioma.

Sonography of liver at 85/12 and 86/7 showed hemangioma but with increased size to 5.8*5.3*3.5cm and 7*7*5.2cm respectively. Triphasic.

CT scan (85/12) showed massive hypodense mass 95*79 mm in left lobe that after injection of IV contrast, severe increased absorption was seen in upper segment and no absorption in the central. It can be atypical hemangioma. In color doppler sonography solid, multilobolated, echogenic mass was reported that has been hypervascular in peripheral portion and hypovascular in central, most aptly hemangioma.

Sonography (85/12): there was a hyoerechoic mass (9.5*6 cm) with several hypoechoic masses inside it. Hemangiopericytoma is suspected. No free fluid in abdomen. Others NL.

MRI (87/1): images reveal bulky lobulated mass lesion in left lobe of the liver with compression upon right portal vein and biliary tracts and included possible central necrotic core. Mass is showing heterogeneous post contrast enhancement not typically-related to hemangioma. Bulky well-defined mass lesion may be compatible with complicated hemangioma; however malignant element cannot be ruled out definitely.

Triphasic CT scan (87/2): Tumor size is 15cm. Although there is more enhancement and partial isodensity in some of the visualized parts of this mass in delayed images, but most of this lesion is not significantly enhanced in the delayed images. This is not compatible with a typical hemangioma. Differentials include atypical hemangioma and or an aggressive tumor of the liver. There is a suspicious polypoid lesion in the right cecum that can be a tumor or focal spasm or fecal materials.

Tc99-RBC liver scan (87/2/10): angiographic images reveal a large photon deficient area in the right liver lobe, which is not filled on the delayed views. On SPECT views the lesion remained photon deficient with areas of absent activity. The study suggests a large space occupying lesion (SOL) in the right hepatic lobe, which shows no evidence in favor of hemangioma.

Colonoscopy (87/2/2): Colonoscope was passed up to cecum and terminal ileum was intubated. There were multiple medium size diverticulums that have mainly involved transverse and descending colon. There was a sessile polyp 1 cm in size just inferior to appendiceal orifice. Polypectomy was done. Some tellangectatasic pinpoint lesions of cecum also were noted. Biopsies were taken.

Colon mucosal biopsy: Mild chronic nonspecific inflammation, intact mucosa, focal dilated capillaries and 2 lymphoid aggregates. Vascular ectasia is a possible diagnosis. Pathology of small sessile polyp: Mild chronic nonspecific inflammation, intact mucosa. One lymphoid aggregate is seen. No evidence of neoplastic polyp.

CT guided liver biopsy (87/1/7): Macroscopy: Two pieces 1.8*0.1cm Microscopy: sections show fragments of fibrous tissue and bile lakes coexisting necrotic debris. Few fragmented normal liver parenchyma is also seen.

Diagnosis: abscess wall Negative for malignancy.

At 87/2/23 he was undergone surgical resection of liver mass.

Dr. Rahimi GI fellow of Shariati hospital