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INCIDENTAL FINDINGS

INCIDENTAL FINDINGS. Joel Thompson, MSIII November 19, 2008. History. 36 yo M (158 kg) presents to the ED c/o BL renal colic, R>L CBC, BMP, LFT’s, lipase, alb, protein, UA all unremarkable except: Glucose 366 Alk Phos 160 (normal 38-126) Glucosuria and trace ketonuria

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INCIDENTAL FINDINGS

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  1. INCIDENTAL FINDINGS Joel Thompson, MSIII November 19, 2008

  2. History • 36 yo M (158 kg) presents to the ED c/o BL renal colic, R>L • CBC, BMP, LFT’s, lipase, alb, protein, UA all unremarkable except: • Glucose 366 • Alk Phos 160 (normal 38-126) • Glucosuria and trace ketonuria • CT A/P stone protocol was performed

  3. 1.87 cm

  4. 26 cm

  5. 17.6 cm

  6. Results • Possible <1mm stone in proximal left ureter • Hepatomegaly (C-C 26 cm, nml < 16 cm)1 • Splenomegaly (C-C 17.6 cm, nml < 13 cm)2 • Nodular contour of liver • Hypertrophied left lateral and caudate lobes • Recanalization of the umbilical vein • Mild dilation of portal vein (1.8 cm) • 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.

  7. CIRRHOSIS!!! (with related portal hypertension) • Cirrhosis is late state of hepatic fibrosis—late cirrhosis is generally irreversible • Distorted hepatic architecture and regenerative nodules • Can be caused by a litany of diseases, including: • Alcoholic liver disease, Hep B/C, NASH (?), PBC, PSC, autoimmune hepatitis, hemochromatosis, Wilson’s disease, alpha-1-antitrypsin deficiency, cardiac cirrhosis • Physical findings include: • Spider angiomata, gynecomastia, palmar erythema, nail changes, clubbing/HPOA, Dupuytren’s contracture, HSM, testicular atrophy, ascites, caput medusae, jaundice, fetor hepaticus, asterixis • Can lead to HCC Goldberg, E and S Chopra. “Diagnostic approach to the patient with cirrhosis.” Uptodate.com. Accessed November 19, 2008.

  8. Role of Radiology • Cirrhosis is a pathologic diagnosis, so radiology can only suggest the diagnosis • Can evaluate for complications of cirrhosis (e.g. ascites, HCC, hepatic/portal vein thrombosis, etc.) and, rarely, can reveal etiology of cirrhosis • Ultrasound is routinely used in evaluation—can be used as screening tool for HCC and portal hypertension • “Stiffness measurement”—increased liver scarring causes increased liver “stiffness”—a newer ultrasound device is used to evaluate • Very helpful with advanced fibrosis • Little role or unclear role for CT/MRI—MRI may be helpful in determining Child-Pugh score, but use is still limited Goldberg, E and S Chopra. “Diagnostic approach to the patient with cirrhosis.” Uptodate.com. Accessed November 19, 2008.

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