Case Report of patient RE

1
Radiological Category
Principal Modality (1) Principal Modality (2)
Gastrointestinal
MRI
Angiography
Case Report of patient RE
Submitted by
Jesse M Proett, MS4
Faculty reviewer
Sandra Oldham, M.D
Date accepted
29 August 2007
Presentation for Radiology 4001
2
Case History

• RE is a 62 yo man with cirrhosis and ESLD likely
  secondary to NASH and portal HTN. He has a MELD
  score of 18 and is currently on the liver
  transplant list. On his last appointment he was
  found to have an elevated AFP of 153.8 (Ref Range
  lt15).
• He had core needle biopsies of the liver on
  5/4/2005 and also in 2001 in Denver. RE also had
  a jet ski accident in 1992 resulting in a leg
  fracture and additional traumas in 2002 and 2004
  requiring hand and wrist surgery. There was no
  reported trauma to the liver other than the
  biopsies.

3
Radiological Presentations
4
Radiological Presentations
5
Radiological Presentations
6
Test Your Diagnosis
Which one of the following is your choice for the
appropriate diagnosis?

• Hepatocellular Carcinoma
• Hepatic Adenoma
• Hemangioma
• Focal Nodular Hyperplasia
• Hepatic Cysts
• Vascular Abnormality

7
The liver demonstrates a heterogeneous
appearance, and there is some nodularity
associated with its contour. Decreased intensity
is noted in the left lobe in non-contrast,
dynamic, and delayed images. On the dynamic
images there is an area of blush seen near the
dome. This is felt to represent an area of
increased vascularity. There is no evidence of
washout, enhancing capsule, or discrete mass
lesion. The portal vein is enlarged measuring
16mm.
Findings and Differentials
Findings
Differentials

• Hepatocellular Carcinoma
• Hepatic Adenoma
• Hemangioma
• Focal Nodular Hyperplasia
• Vascular Abnormality

8
Radiological Presentations
9
Radiological Presentations
10
Radiological Presentations
11
Discussion

• Hepatocellular Carcinoma
• Lesion must be larger than 3cm
• Hyperintense appearance in T2W images
• Intense enhancement in the arterial dominant
  phase
• Late washout
• Presence of capsule
• Tendency to invade the portal and hepatic veins
• Rapid growth
• Hepatic Adenoma
• MRI characteristics are highly variable
• Hyperintense on T1 and T2W images due to the
  presence of fat and/or glycogen
• Greater enhancement on T2W images with
  gadolinium is highly suggestive of the diagnosis
• Gadolinium enhancement is early, after which
  the lesion becomes isointense

12
Discussion

• Hemangioma
• Hypointense in T1W images
• Hyperintense in T2W images
• Smooth, well-demarcated borders
• Ring-like enhancement 1 minute after contrast
  is given
• Wash-out, which causes a heterogeneous
  appearance, and observation of a uniform, thick
  ring
• Focal Nodular Hyperplasia
• They are hypo- or isointense on T1W images
• Mildly hyper- or isointense on T2W images
• Rapid enhancement in the early arterial phase
• Washout in the late phase is observed
• Central scar tissue shows late enhancement

13
Discussion

• Vascular Abnormality
• MRI is not the ideal modality to diagnose
  vascular abnormalities
• Angiography is the gold standard for diagnosis.
• The decreased intensity in the left lobe of the
  liver through both non-contrast and contrast
  images does indicate a possible vasculature
  etiology
• The area of high intensity during the dynamic
  phase suggests increased vascularity with no
  evidence of a discrete mass
• Hepatic US showed no evidence of abnormal blood
  flow on 4/29/2005 before his core needle biopsy
  on 5/4/2005.

14
Discussion

• A diagnosis could not be made based on the MRI.
• Further evaluation is needed to rule out
  malignancy.
• A lipiodol study was ordered to visualize a
  possible HCC.
• Lipiodol is an embolic agent used in
  angiography that allows us to visualize HCC
  because the embolic agent stays in the mass.

15
Radiological Presentations
16
Radiological Presentations
17
Radiological Presentations
18
Radiological Presentations
19
Intrahepatic Arterioportal Fistula (APF)
Diagnosis
20
Etiology Acquired Trauma - blunt
or penetrating Iatrogenic - interventional
hepatic procedures, liver biopsies, percutaneous
transhepatic cholangiography, ruptured
splanchnic artery aneurysms, transhepatic
catheterization of bile ducts Tumors -
especially hepatocellular carcinoma Liver
Transplant Other - Hemangiomas, cirrhosis,
regenerating liver nodules, hepatic abscess,
Budd- Chiari syndrome, hereditary hemorrhagic
telangiectasia, and Ehlers-Danlos
Congenital - typically presents very early in
life (neonate 10yo)
Diagnosis
21
Liver biopsy - 52 of the patients who had an
arteriogram performed within 1 week following
liver biopsy. This rate decreased to 10 if the
arteriogram was performed 3 weeks after liver
biopsy. These data suggest most small,
peripheral, asymptomatic fistulas caused by liver
biopsy will disappear spontaneously within 1
month.Trauma - The majority of APFs are due to
blunt or penetrating trauma. APFs develop more
frequently from penetrating trauma. In some
cases the traumatic event can be decades before
the presentation of the APF.Cirrhosis - AFPs
due to cirrhosis are more commonly peripheral and
asymptomatic.
Diagnosis
22
(No Transcript)
23
Ultrasound - US is a useful tool in screening
patients with cirrhosis or those at risk of
acquiring APFs. RE did have an US of his
abdomen, and at that time there was no mention of
an APF. Finding on his US on 4/29/2005 include
portal vein 4.5mm with no detectable flow within
the main portal vein.MRI - This is not a
diagnostic study for the evaluation of APFs, but
there are some subtle signs. APFs can induce
focal sparing in the diffuse fatty liver through
increased non-lipid-rich arterial flow and
decreased lipid-rich portal flow. This means
that in the area affected by the APF there can be
decreased signal which is what we observed on
MRI. Much in the same way gadolinium will also
be shunted away from the areas affected by the
APF.Angiography - This is the gold standard for
diagnosing APFs. Contrast material is seen
immediately entering the portal circulation.
Diagnosis
24
Proposed ClassificationType 1- Small,
peripheral, intrahepatic fistulas with minimal
physiologic consequences- Commonly secondary to
liver biopsy- Usually thrombose spontaneously
lt1mo- Follow with US or embolize if persistent
gt1mo and/or become symptomaticType 2- Larger,
more central fistulas with enough flow to cause
elevated portal pressures- Most are secondary
to penetrating trauma- Cause portal
hypertension and hepatoportal sclerosis and can
progress to portal fibrosis- Treat with
embolization if possible or surgery for
complicated casesType 3- Diffuse intrahepatic
APFs- Congenital- Cause severe portal
hypertension in infancy- Refer to a specialized
pediatric hepatobiliary center. Treatment may
consist of hepatic artery ligation, embolization,
resection, or liver transplantation
Diagnosis
25
Radiological Presentations
26
1. Guzman EA, McCahill LE, Rogers FB.
Arterioportal fistulas introduction of a novel
classification with therapeutic implications.
J Gastrointest Surg 200610543550.2. Bilgili
Y,Firat Z, Pamuklar E, et al. Focal liver lesions
evaluated by MR imaging. Diagn Interv Radiol
2006 12129-135.3. Bolognesi M, et al.
Arterioportal fistulas in patients with liver
cirrhosis usefulness of color doppler US
for screening. Radiology 2000 216738743. 4.
Choi BI, Lee KH, Han JK, Lee JM, et al. Hepatic
arterioportal shunts dynamic CT and MR
features. Kor J Radiol 20023115. 5.
UpToDate
References