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 CT A/P stone protocol was performed 1.87 cm 26 cm 17.6 cm 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. 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. 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.