Huge hepatomegalia

Clinical History

The patient presented with body weakness, loss of appetite, dizziness and dyspnoea on effort. Her skin became dry and brown.
Laboratory blood tests showed anaemia, high values of ALT, AST, urea and creatinine.
Palpation showed hard and painless abdomen. During inspection the abdomen appeared like 8 months pregnant.

Imaging Findings

In US it was impossible to evaluate the liver size. Liver ultrasound appearance was nodular, heterogeneous and irregular from right to the left, from epigastrum to pelvis. The spleen was normal. Both kidneys were hyperechogenic. Minimal free liquid in cavity was present. Renal colour Doppler was not performed because the US machine of EMD does not have this option. For the same reason it was impossible to evaluate the portal system.
Creatinine level was 10 mg/dl. In our department we absolutely do not administer iodine CM at patients with creatinine level higher than 2.4 mg/dl (or creatinine clearence < 30 ml/min) so abdominal CT without CM was performed
In CT enormous heterogeneous nodular liver 37x30x22 cm was found and minimal free liquid, both kidneys appeared isointense to liver and the spleen was normal.
MRI was not performed because the patient had metallic shift on her right femur.

Discussion

Hepatic cirrhosis is a reaction of the liver to chronic hepatocyte injury and is often classified morphologically into micronodular and macronodular.
A micronodular pattern predominates in alcohol-induced cirrhosis (also called portal or nutritional cirrhosis), while viral hepatitis generally has more of a macronodular appearance, but such a differentiation is not clear-cut, overlap exists, and with time micronodular cirrhosis tends to evolve into a mixed or macronodular appearance.
Aetiologies of cirrhosis range from infectious, chemical, metabolic, and immunologic, to idiopathic. In Asia and in Albania chronic hepatitis predominates. [1]
Our patient had a history of hepatitis B in the past and she was HBsAg positive.
Liver US is probably the most common screening examination performed in patients with suspected diffuse liver disease and their routine follow-up. In cirrhosis bands of fibrous tissue are laid down in the liver parenchyma between the hepatic lobules. This distorts and destroys the normal architecture of the liver, separating it into nodules. The process may be micronodular, which gives a generally coarse echotexture (bright liver) or macronodular in which discrete nodules of 1 cm and above can be distinguished on ultrasound [2]. US is a useful examination to evaluate even if the other abdominal structures and organs are affected by the cirrhosis.
In chronic stages the liver size is shrunken or enlarged, the border mostly is irregular and the ratio between caudate lobe and left lobe is inverted. Portal system is collapsed and compensatory drainage veins are developed.
CT is not the best examination method to determine the radiological diagnosis, especially without contrast media administration, but it can exactly determine the liver size and its relations. A CT based caudate-to-right lobe ratio of >0.65 is strong presumptive evidence for cirrhosis. Cirrhosis markedly distorts the hepatic parenchyma, producing a smooth, nodular, or lobular hepatic capsule in the majority of cases. Margins that are either smooth or deformed by multiple small nodules are typically seen in micronodular cirrhosis. These micronodules underlying the surface of the liver are often not visualised on MDCT or MRI. On the other hand the macronodular aspect of liver is well visualised by CT.
MRI and contrast enhancement MRI are better than CT when it is possible.
In our case was impossible to perform the MRI, that's why is was difficult to differentiate this case from a hepatocellular carcinoma until the biopsy was performed three days later, which confirmed the macronodular hepatic cirrhosis.

Differential Diagnosis List

Final Diagnosis

Hepatic macronodular cirrhosis with ascites

URL:	https://www.eurorad.org/case/10018
DOI:	10.1594/EURORAD/CASE.10018
ISSN:	1563-4086