NMS. Casos Clínicos

205

Chapter 7 ♦ Pancreatic and Hepatic Disorders

Case 7.17 Hepatic Mass A 37-year-old woman is seen for vague RUQ pain. Laboratory studies are normal. An RUQ ultrasound study reveals no gallstones but does show a 3 × 4-cm mass in the right lobe of the liver. Q: What common diagnoses do these findings represent? A: Most likely, this lesion is benign. If cystic on ultrasound, it is probably a simple cyst . If solid , the most common diagnosis is a “ hemangioma. ” Other likely tumors include focal nodular hyperplasia and hepatic adenoma. Metastatic carcinoma, primary hepatocellular carcinoma, and cholangiocarcinoma are possible but less likely at this age. Q: What specific patient history information and physical exam findings would you look for? A: Inquiries regarding history of use of oral birth control pills, exposure to environmental toxins, hepatitis B and C, previous injury to the liver, and known primary tumors are neces- sary. On physical examination, signs of chronic liver disease, including cirrhosis, polycystic kidney disease, and primary kidney tumors, should be sought.

Q: How would you evaluate and manage the following types of lesions?

Case Variation 7.17.1. Cystic lesion with no internal echoes suggestive of a simple cyst (Fig. 7-27) ◆ ◆ Although a simple cyst can cause symptoms of RUQ discomfort, it is asymptomatic in most cases. Rarely, a hepatic cyst may develop hemorrhage, secondary bacterial infection, or obstructive jaundice. Generally, a simple cyst needs no further management . If signifi- cant symptoms persist, treatment of the cyst with aspiration followed by a sclerosant or by simple excision is warranted. If multiple cysts are present in the liver in a patient who also has polycystic kidney disease, the patient has polycystic liver disease. Treatment is similar to that for simple cysts of the liver. Case Variation 7.17.2. Multilocular cyst with calcifications in the wall and internal echoes (Fig. 7-28) ◆ ◆ A suspected echinococcal cyst , which results from Echinococcus granulosus , a GI parasite, may be present. The serologic test for Echinococcus is usually positive. Small cysts (single compartment <5 cm) can be treated with antibiotics albendazole or mebendazole. Larger cysts can be treated with aspiration and injection of a scolocidal agent such as hypertonic saline or alcohol. ◆ ◆ Surgical treatment for more complicated cysts is aimed at operative sterilization of the cyst by injecting the cyst under controlled operative conditions using a scolocidal agent, followed by excision of the cyst . It is necessary to take care not to spill the cyst contents into the peritoneum, which could allow them to infect the peritoneal cavity or produce an anaphylactic reaction. Case Variation 7.17.3. Cystic lesion suggestive of an abscess ◆ ◆ A hepatic abscess usually presents with fever, elevated WBC count, and abdominal tender- ness. Treatment of a pyogenic (i.e., bacterial) abscess should consist of IV antibiotics and SAMPLE