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INCIDENTAL FINDINGS

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INCIDENTAL FINDINGS Powered By Docstoc
					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.