NMS. Casos Clínicos

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Chapter 7 ♦ Pancreatic and Hepatic Disorders

CT-guided drainage . In most cases, resection can be avoided. An amebic abscess may be treated with metronidazole alone and no surgery. Case Variation 7.17.4. Solid-appearing lesion (Fig. 7-29) ◆ ◆ The differential diagnosis for a solid liver lesion includes hemangioma, focal nodular hyperplasia, hepatic adenoma, metastatic cancer, and hepatocellular carcinoma . The history is important. Pertinent findings include oral contraceptive use, which is present in a high percentage (as high as 90%) of patients with hepatic adenoma and occurs less frequently in patients with focal nodular hyperplasia. A history of hepatitis (B or C) or cirrhosis may suggest hepatocellular carcinoma. ◆ ◆ Note that serum-based liver studies may be unremarkable in individuals with any one of these three conditions. Alpha-fetoprotein, as well as hepatitis B surface antigen, may be positive in patients with hepatocellular carcinoma. Q: How would you establish the diagnosis? A: A hemangioma is a collection of ectatic vascular cavernous spaces lined by endothelium. Magnetic resonance imaging (MRI) with IV gadolinium is the best test to diagnose a he- patic hemangioma, which has a characteristic appearance of a vascular lesion that fills from the periphery to the center (Fig. 7-30). A labeled red blood cell scan or a bolus-enhanced dynamic CT scan is also highly reliable in making the diagnosis of a hemangioma. The discovery of most hemangiomas is incidental; it occurs during an ultrasound examination to check for gallstones. Hemangiomas are usually asymptomatic and almost never present with spontaneous hemorrhage. Thus, removal is not warranted. Most sur- geons use the following as a general guideline for surgical removal of benign hepatic masses: Biopsy of a hepatic lesion should only be performed after it is certain that the le- sion is not a hemangioma because of a high risk of bleeding. Hepatic adenoma also has a high bleeding risk with biopsy. Thus, biopsy is only performed selectively to confirm a di- agnosis. Significant symptomatic lesions, lesions with a risk of spontaneous rupture, and lesions with uncertainty as to the diagnosis warrant removal. The lesion is solid. You suspect a hemangioma.

You obtain an MRI. It is negative for hemangioma.

Mass Figure 7-29: CT scan of solid liver lesion. SAMPLE