INCIDENTAL FINDINGSINCIDENTAL FINDINGS

Joel Thompson, MSIIIJoel Thompson, MSIII

November 19, 2008November 19, 2008

HistoryHistory

36 yo M (158 kg) presents to the ED c/o 36 yo M (158 kg) presents to the ED c/o BL renal colic, R>LBL renal colic, R>L

CBC, BMP, LFT’s, lipase, alb, protein, UA CBC, BMP, LFT’s, lipase, alb, protein, UA all unremarkable except:all unremarkable except:– Glucose 366Glucose 366– Alk Phos 160 (normal 38-126)Alk Phos 160 (normal 38-126)– Glucosuria and trace ketonuriaGlucosuria and trace ketonuria

CT A/P stone protocol was performedCT A/P stone protocol was performed

1.87 cm

26 cm

17.6 cm

ResultsResults

PossiblePossible <1mm stone in proximal left ureter <1mm stone in proximal left ureter

Hepatomegaly (C-C 26 cm, nml < 16 cm)Hepatomegaly (C-C 26 cm, nml < 16 cm)11

Splenomegaly (C-C 17.6 cm, nml < 13 cm)Splenomegaly (C-C 17.6 cm, nml < 13 cm)22

Nodular contour of liverNodular contour of liver

Hypertrophied left lateral and caudate lobesHypertrophied left lateral and caudate lobes

Recanalization of the umbilical veinRecanalization of the umbilical vein

Mild dilation of portal vein (1.8 cm)Mild dilation of portal vein (1.8 cm)

ALL FINDINGS SUGGESTIVE OF…ALL FINDINGS SUGGESTIVE OF…1. Akbar, DH and AH Kawther. “Nonalcoholic Fatty Liver Disease in Saudi Type 2 Diabetic Subjects Attending a Medical Outpatient Clinic.” Diabetes Care 26:3351-3352, 2003.

2. McClain, KL and SA Landow. “Approach to the child with an enlarged spleen.” Uptodate.com. Accessed November 18, 2008.

CIRRHOSIS!!! (with related portal CIRRHOSIS!!! (with related portal hypertension)hypertension)

Cirrhosis is late state of hepatic fibrosis—late Cirrhosis is late state of hepatic fibrosis—late cirrhosis is generally irreversiblecirrhosis is generally irreversible– Distorted hepatic architecture and regenerative nodulesDistorted hepatic architecture and regenerative nodules

Can be caused by a litany of diseases, including:Can be caused by a litany of diseases, including:– Alcoholic liver disease, Hep B/C, NASH (?), PBC, PSC, Alcoholic liver disease, Hep B/C, NASH (?), PBC, PSC,

autoimmune hepatitis, hemochromatosis, Wilson’s autoimmune hepatitis, hemochromatosis, Wilson’s disease, alpha-1-antitrypsin deficiency, cardiac cirrhosisdisease, alpha-1-antitrypsin deficiency, cardiac cirrhosis

Physical findings include:Physical findings include:– Spider angiomata, gynecomastia, palmar erythema, nail Spider angiomata, gynecomastia, palmar erythema, nail

changes, clubbing/HPOA, Dupuytren’s contracture, HSM, changes, clubbing/HPOA, Dupuytren’s contracture, HSM, testicular atrophy, ascites, caput medusae, jaundice, fetor testicular atrophy, ascites, caput medusae, jaundice, fetor hepaticus, asterixishepaticus, asterixis

– Can lead to HCCCan lead to HCC

Goldberg, E and S Chopra. “Diagnostic approach to the patient with cirrhosis.” Uptodate.com. Accessed November 19, 2008.

Role of RadiologyRole of RadiologyCirrhosis is a pathologic diagnosis, so radiology can Cirrhosis is a pathologic diagnosis, so radiology can only only suggestsuggest the diagnosis the diagnosis– Can evaluate for complications of cirrhosis (e.g. ascites, Can evaluate for complications of cirrhosis (e.g. ascites,

HCC, hepatic/portal vein thrombosis, etc.) and, rarely, can HCC, hepatic/portal vein thrombosis, etc.) and, rarely, can reveal etiology of cirrhosisreveal etiology of cirrhosis

Ultrasound is routinely used in evaluation—can be Ultrasound is routinely used in evaluation—can be used as screening tool for HCC and portal used as screening tool for HCC and portal hypertensionhypertension– ““Stiffness measurement”—increased liver scarring causes Stiffness measurement”—increased liver scarring causes

increased liver “stiffness”—a newer ultrasound device is increased liver “stiffness”—a newer ultrasound device is used to evaluateused to evaluate

– Very helpful with advanced fibrosisVery helpful with advanced fibrosis

Little role or unclear role for CT/MRI—MRI may be Little role or unclear role for CT/MRI—MRI may be helpful in determining Child-Pugh score, but use is helpful in determining Child-Pugh score, but use is still limitedstill limited

Goldberg, E and S Chopra. “Diagnostic approach to the patient with cirrhosis.” Uptodate.com. Accessed November 19, 2008.