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20

Ultrasound Atlas of Clinical Cases

Department of Gastroenterology and Hepatology,

“Victor Babeș” University of Medicine and Pharmacy Timișoara

Prof. Ioan Sporea, MD, PhD, Editor

First Edition

2020

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1

Authors:

Prof. Ioan Sporea, MD, PhD, Editor Prof. Alina Popescu, MD, PhD

Prof. Roxana Șirli, MD, PhD Mirela Dănilă, MD, PhD

Felix Bende, MD, PhD

Ana-Maria Ghiuchici, MD

Ruxandra Mare, MD, PhD

Tudor Moga, MD, PhD

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Editura „Victor Babeş”

Piaţa Eftimie Murgu nr. 2, cam. 316, 300041 Timişoara Tel./ Fax 0256 495 210

e-mail: [email protected] www.umft.ro/editura

Director general: Prof. univ. emerit dr. Dan V. Poenaru

Colecţia: MANUALE

Coordonator colecţie: Prof. univ. dr. Sorin Eugen Boia

Referent științific: Prof. univ. dr. Lucian Petrescu

Indicativ CNCSIS: 324

© 2020

Toate drepturile asupra acestei ediţii sunt rezervate.

Reproducerea parţială sau integrală a textului, pe orice suport, fără acordul scris al autoarelor este interzisă şi se va sancţiona conform legilor în vigoare.

ISBN 978-606-786-189-1

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Level of difficulty

A- Advanced Ultrasound Cases; B- Basic Ultrasound Cases Contents

1. Case 1 Biliary tract (B): Multiple gallbladder polyps. 5

2. Case 2 Biliary tract (B): Biliary sludge. 8

3. Case 3 Biliary tract (B): “Ball-like” biliary sludge. 11

4. Case 4 Biliary tract (A): Acute cholecistitis. 15

5. Case 5 Biliary tract (A): Caroli disease type I. 20

6. Case 6 Biliary tract (A): Obstructive jaundice due to choledocholithiasis. 24

7. Case 7 Liver (B): Liver Abscess. 27

8. Case 8 Liver (B): Hydatic cyst type IV. 30

9. Case 9 Liver (B): Hypervascular liver metastases. 32

10. Case 10 Liver (B): Focal Fatty Infiltration. 36

11. Case 11 Liver (B): Liver hemangioma. 40

12. Case 12 Liver (A): Fibrolamellar hepatocellular carcinoma. 43 13. Case 13 Liver (A): Spontaneous intrahepatic rupture of a hepatocellular

adenoma.

48

14. Case 14 Liver (A): Liver abscess. 55

15. Case 15 Liver (A): Partial benign portal vein thrombosis. 59

16. Case 16 Liver (A): Focal nodular hyperplasia (FNH). 63

17. Case 17 Liver (A): Liver Abscess. 67

18. Case 18 Liver (A): Weakly differentiated Hepatocellular Carcinoma (G3). 70

19. Case 19 Liver (A): Cyst-Adenoma. 75

20. Case 20 Liver (A): Liver abceses and hepatic artery pseudoaneurism. 80

21. Case 21 Liver (A): Liver Abscess. 86

22. Case 22 Liver (A): Intrahepatic cholangiocarcinoma, complicated with liver metastases. Malignant portal thrombosis. Biliary lithiasis.

90 23. Case 23 Liver (A): Obstructive jaundice due to intrabiliary rupture of liver

hydatic cyst.

94 24. Case 24 Liver (A): Subfrenic abscess- an inaugural complication of gastric

cancer.

98 25. Case 25 GI tract (A): Suboclusive syndrom in a patient with Crohn’s disease. 101 26. Case 26 GI tract (A): Gastric outlet obstruction and obstructive jaundice

secondary to a cephalic pancreatic neoplasia.

104 27. Case 27 GI tract (A): Crohn’s disease of the small bowell and colon. 108

28. Case 28 GI tract (A): Acute edematous appendicitis. 111

29. Case 29 GI tract (A): Acute appendicitis. 114

30. Case 30 Kidney (B): Uretero-hydronephrosis and ascites. 117

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Introduction

Ultrasound is the most used imaging method in clinical practice. It has developed a lot in the last two decades, and the introduction of contrast- enhanced ultrasound (CEUS) made it very competitive with the other cross- sectional imaging methods. Being very cheap and available quite everywhere, this method is used a lot in clinical practice, for inpatients, but also for outpatients.

Ultrasound is a useful tool for quite all specialties, thus training should begin early, even by students and, for sure, should continue during fellowship.

In daily practice, ultrasound machines have different sizes and performance. Pocket ultrasound is useful for bedside examination, while large and expensive systems are used for advanced ultrasound, such as CEUS evaluation, elastography, Doppler, etc.

Clinical ultrasound means that the examiner is aware of clinical information regarding the patient, sometimes of biological tests, and ultrasound is used to make decisions regarding diagnosis and treatment. In many cases, standard ultrasound examination can lead to the final diagnosis, but sometimes, a CEUS examination or other imaging techniques are needed. In some cases, echo-guided interventional procedures need to be performed.

In this collection of abdominal ultrasound cases, the authors try to show how and when to use abdominal ultrasound in a clinical scenario, when to use a CEUS examination, and when other modality of diagnosis are needed. In this cases collection, the presentation of the patients’ clinical signs is followed by images from the ultrasound exam, which are subsequently explained, followed by discussions that explain the clinical judgment.

This collection of cases includes only abdominal ultrasound, focused on the gastroenterological field. The level of presented cases is basic or advanced and can be used for all who like ultrasound.

The authors

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Case 1 Biliary tract (B)

History: a 34-year-old male patient, asymptomatic, with no significant pathology (no prior hospitalization and surgery), presented for a routine clinical and ultrasound evaluation.

The clinical examination did not reveal any abnormalities.

Laboratory tests – normal complete blood cound, normal levels of AST and ALT, normal urine test.

Abdominal ultrasound examination was performed (Fig. 1.1 – 1.5).

Fig. 1.1 Fig. 1.2

Fig. 1.3 Fig. 1.4

Fig. 1.5

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Abdominal ultrasound findings were (Fig. 1.6 A, B, C):

Fig. 1.6. A,B,C – Multiple gallbladder polyps: multiple hyperechoic structures with variable sizes (smaller than 1 cm), attached to the gallbladder wall, with no posterior acoustic shadowing; the structures do not move with a change in patient’s position; intact gallbladder wall.

Discussion

 Gallbladder polyps are outgrowths of the gallbladder mucosal wall, usually found incidentally on abdominal ultrasound or after cholecystectomy.

 Polypoid lesions in the gallbladder can be divided in benign or malignant lesions. Benign galllbladder polyps are subdivided into benign neoplastic lesions (such as adenoma) and benign non-neoplastic lesions (such as cholesterol polyps, adenomyomas, inflammatory polyps). Correct diagnosis would help reduce unnecessary cholecystectomies [1].

A B

C

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 The majority of gallbadder polyps are benign, but malignant transformation is an important concern as gallbladder cancer has poor prognosis. Resection at an early stage is the only hope for cure.

 Growing gallblader polyps or polyps larger than 10 mm should be removed surgically (cholecistectomy) to prevent malingnant transformation.

 A study of Hui-Ping Zhang et. al showed that CEUS helped in the differential diagnosis among different kinds of gallbladder lesions, improving diagnostic efficiency. According to this study, CEUS examination could be used as a further diagnostic method if a definite diagnosis could not be made using conventional ultrasound [2].

 Follow-up: ultrasound every six months for a year and then yearly if the polip size is stable.

Final diagnostic: Multiple gallbladder polyps.

References:

1. Liu XS, Chen T, Gu LH, et al.Ultrasound-based scoring system for differential diagnosis of polypoid lesions of the gallbladder. J Gastroenterol Hepatol. 2018 Jun;33(6):1295-1299.

2. Zhang HP, Bai M, Gu JY, et al. Value of contrast-enhanced ultrasound in the differential diagnosis of gallbladder lesion. World J Gastroenterol. Feb 14, 2018; 24(6): 744-751.

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Case 2 Biliary tract (B)

History: a 68-year-old male patient, with atrial fibrillation, on anticoagulant treatment, presented himself for the evaluation of mild epigastric pain.

Clinical exam – mild pain at epigastric palpation, BP 120/70 mmHg, AV 74 beats/min arrhythmic.

Biology:

 mild sideropenic anemia (Hb 11 g%, iron 33 µg/ml)

 no cytolysis, no cholestasis.

Abdominal ultrasound: - Fig. 2.1 and 2.2

Fig. 2.1

Fig. 2.2

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9

Abdominal Ultrasound

Fig. 2.1 Fig. 2.2

Fig. 2.1 and Fig. 2.2. Gallbladder with thin walls. Inside the gallbladder a round hyperechoic lesion, of approximately 5 cm in diameter is seen. It does not change the size, shape, or position when the patient turns from dorsal to lateral decubitus. There is also some loose hyperechoic material, with no posterior shadowing, floating in the fundus of the gallbladder.

Possible diagnoses:

o Gallbladder polyp or cancer (round hyperechoic lesion that does not change size, shape and position).

o Biliary sludge.

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Contrast enhanced ultrasound was performed for the differential diagnosis (Fig. 2.3).

Fig. 2.3

Fig. 2.3 - The lesion inside the gallbladder was unenhancing in all vascular phases. So that the final diagnosis was biliary sludge.

Discussion

 The presence of a round hyperechoic lesion inside the gallbladder that does not change size, shape and position is highly suspicious for a gallbladder polyp. A polyp this size should be most probably malignant, but no changes of the gallbladder wall could be observed.

 CEUS excluded the diagnosis of gallbladder polyp or cancer since the lesion was avascular.

 Further work-up of the patient included a gastroscopy, which revealed a benign gastric ulcer (that can explain the epigastric pain and anemia in a patient on anticoagulants).

Colonoscopy is scheduled.

Final diagnosis: Biliary sludge.

References:

1. Claudon M, Dietrich CF, Choi BI, et al. Guidelines and good clinical practice recommendations for contrast enhanced ultrasound (CEUS) in the liver: update 2012—a WFUMB-EFSUMB initiative in cooperation with representatives of AFSUMB, AIUM, ASUM, FLAUS and ICUS. Ultraschall Med 2013;

34:11–29.

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11

Case 3 Biliary tract (B)

Clinical presentation: a 52 years-old-female was admitted in our department with recurrent epigastric pain.

Laboratory findings revealed increased liver function test (AST: 88 U/L [5-45], ALT: 72 U/L [5-55], T.bilirubin: 1.2 mg/dL [0-1.2], D.bilirubin: 0.9 mg/dL [0-0.3], ALP: 79 U/L [35- 104], GGT: 48 U/L [7-50], leucocytes: 10.200/uL [4.500-9500]).

Abdominal Ultrasound: Fig. 3.1-3.3.

Fig. 3.1. Fig. 3.2.

Fig. 3.3

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Abdominal Ultrasound: Fig. 3.1-3.3

Fig. 3.1. Fig. 3.2.

Fig. 3.3

Abdominal Ultrasound: Fig. 3.1-3.3 revealed a homogenous gallblader lesion 6/2 cm in diameter, which did not move after changing patients’ position and did not present posterior shadowing.

Differential diagnosis include:

o Gallbladder sludge o Gallbladder tumor

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Contrast enhanced ultrasound was performed for the differential diagnosis (Fig. 3.4- 3.5)

Fig. 3.4 Fig. 3.5

Fig. 3.6

Fig. 3.4-3.6. CEUS – The lesion is unenhancing in the arterial (Fig. 3.4), portal (Fig. 3.5) and late (Fig.3.6) phases.

Discussion

 Billiary sludge is a mixture of mucus, calcium bilirubinate and cholesterol crystals and is the consequence of imbalance between bile components alongside poor bile evacuation. By some authors, it is precursor of biliary lithiasis, and by others it is a reversible state [1].

 A particular form of billiary sludge is called ball-like or pseudotumoral sludge, in which the ultrasound appearance is of a globulous ecodense material inside the gallblader, which can retain its shape after patient mobilization or can desintegrate [2].

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 Billiary sludge must be differentiated from gallblader tumours and polyps (easily done by contrast enhanced ultrasound – CEUS: billiary sludge does not enhance following contrast, being avascular, as opposed to tumours and polyps) [3].

Final diagnostic: “Ball-like” biliary sludge.

References:

1. Pazzi P, Gamberini S, Buldrini P, Gullini S. Biliary sludge: the sluggish gallbladder. Digestive and Liver Disease. 2003;35:39-45. doi:10.1016/s1590-8658(03)00093-8.

2. Lee CC, Huang JC, Shin JS, Wu MJ. Tumefactive Sludge Mimicking Gallbladder Neoplasm: A Case Report and Review of the Literature. J Med Ultrasound. 2018;26(2):103‐106.

doi:10.4103/JMU.JMU_19_18.

3. Serra C, Felicani C, Mazzotta E, et al. CEUS in the differential diagnosis between biliary sludge, benign lesions and malignant lesions. J Ultrasound. 2018;21(2):119‐126. doi:10.1007/s40477-018-0286-5.

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Case 4 Biliary tract (A)

History: a 74 years-old-male presented with inappetence, jaundice, fever and mild tenderness in the right upper quadrant pain for three days. The patient`s past medical history showed type 2 diabetes.

Laboratory findings revealed Leucocytosis = 17000/mm3, CRP =167 mg/l, ALT 2.5xUVN, ASAT 1.7xUVN and total bilirubin, 4.5 mg %. The patient`s past medical history showed type 2 diabetes, treated with oral antidiabetics.

Ultrasound examination: Fig.4.A-D

Fig. 4 (A-D)

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Fig. 4. A-D: Ultrasound section for the gallbladder- from left to right there are sections of the gallbladder where a poorly delineated, inhomogeneous area of approximately 10 cm, with hyperechoic inclusions, can be seen.

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17 Contrast enhanced ultrasound: fig 4.2 (C-D)

Fig 4.2 A a poorly delineated, inhomogeneous area of approximately 10 cm, with hyperechoic inclusions, can be seen (arrow).

Fig. 4.2 B. highlights a protrusion from the gallbladder into the liver which can be a discontinuation of the gallbladder wall.

Fig. 4.2 C and D, CEUS (portal and late phases), the gallbladder content is unenhancing, with an obvious unenhancing area (arrow) near the gallbladder wall.

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Additional imaging (Fig. 4.3 A, B)

Figures 4.3 A, B - CT venous phase, axial section: A - distended gallbladder, with thickened walls, suggestive for inflamation and also a gap in the wall of the gallbladder, suggestive for perforation. Fig. B - Gall stones are visible.

Discussion

 Cholecystitis is an inflammation of the gallbladder that occurs most commonly because of an obstruction of the cystic duct by gallstones (cholelithiasis).

 Typical signs of Cholecystitis are intense pain and tenderness in the right hipochondrium, fever, chils

 Cholecystitis may present differently, especially in elderly patients and diabetics. In these cases, the symptoms are vague without key physical findings, with localized tenderness the only presenting sign. These cases may progress to complicated cholecystitis rapidly and without warning.

 Ultrasound examination is the preferred initial imaging test for the diagnosis of acute cholecystitis and cholelithiasis.

 CT is a secondary imaging test that can identify extrabiliary disorders and complications of acute cholecystitis, such as gangrene, gas formation, and perforation.

 In acute cholecystitis, the initial treatment includes fasting, intravenous hydration, correction of electrolyte abnormalities, analgesia, and intravenous antibiotics.

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 Definitive therapy involves cholecystectomy or placement of a drainage device;

therefore, consultation with a surgeon is warranted.

 Consultation with a gastroenterologist for consideration of endoscopic retrograde cholangiopancreatography (ERCP) may also be appropriate, if there is proof of choledocholithiasis.

Final diagnosis: Acute cholecistitis.

References:

1. Jang T, Aubin C, Naunheim R. Minimum training for right upper quadrant ultrasonography. Am J Emerg Med. 2004 Oct. 22(6):439-43.

2. Lee SW, Yang SS, Chang CS,et al. Impact of the Tokyo guidelines on the management of patients with acute calculous cholecystitis. J Gastroenterol Hepatol. 2009 Dec. 24(12):1857-61.

3. Yarmish GM, Smith MP, Rosen MP, et al. ACR appropriateness criteria right upper quadrant pain. J Am Coll Radiol. 2014;11(3):316‐322.

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Case 5 Biliary tract (A)

History: 76 years-old-male, no relevant medical history, presented with right upper abdominal pain, heart burn and bloating.

Laboratory findings revealed normal blood tests with the exception of a mild thrombocytopenia.

Ultrasound examination (Fig 5.1-5.3):

Fig 5.1 Fig.5.2

Fig. 5.3

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Fig . 5.1 Fig. 5.2

Fig. 5.3

Fig. 5.1, 5.2 and 5.3 -Ultrasound evaluation unveiled an atypical B-mode aspect of the liver, with a heterogenous liver structure, that orientated the diagnosis towards a diffuse hepatic disease. Fig. 5.1-5.2 – Normal galbladder is seen.

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Contrast enhanced ultrasound was performed, however the hepatic structure was iso- enhancing in all vascular phases, not showing any abnormality.

Fig 5.4 Iso-enhancement of the liver parenchima in all vascular phases.

Additional Imaging (Fig. 5.5 A-D)

Fig.5.5 (A-D): different MRI sections showing the typical aspect of scattered cystic dilatations communicating with the biliary tree (MRCP), as in Caroli disease.

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Discussion

 Caroli’s disease is a rare, inherited, congenital disorder associated with an incomplete and faulty remodeling of the ductal structure.

 There are two types of Caroli’s disease: type I - which usually has a benign course and type II or Caroli’s syndrome - which is marked by complications that will appear before the age of 40 years.

 Due to the segmental dilatation of the intrahepatic bile ducts, patients presenting CD are more prone to develop intraductal calculi and all the complications related to this.

 No specific symptom or clinical sign in our case.

 Some patients may be asymptomatic - (CD I), whereas patients presenting type II CD may present complications (secondary to cholestasis).

 The final diagnosis is made mainly by imaging methods (CT and MRCP) or bay biposy.

 According to published data, ultrasound accuracy for the diagnosis of CD is approximatelly 30%.

 Even though US can visualize hepatic cystic lesions, intrahepatic lithiasis and provide informations about the bile ducts, it cannot differentiate cystic lesions emerging from other conditions.

 In this case report, we want to underline a miscellaneous US aspect of a CD type I.

Final diagnostic: Caroli disease type I.

References:

1. Zhong-Xia Wang, Yong-Gang Li, Rui-Lin Wang et al. Clinical classification of Caroli's disease: an analysis of 30 patients. International Hepato-Pancreato-Biliary Association. HPB 2015; 17: 278–283.

2. Bettini G, Mandrioli L, Morini M. Bile duct dysplasia and congenital hepatic fibrosis associated with polycystic kidney (Caroli syndrome) in a rat. Vet Pathol 2003;40:693–694.

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Case 6 Biliary tract (A)

History: a 32-year-old female patient was admitted in our department with a 24-hour history of right upper quadrant and epigastric pain, jaundice, nausea, and vomiting. She had similar pain in the past, particularly after eating fatty foods and sweets.

Clinical examination revealed moderate tenderness in the upper quadrant on deep palpation, jaundice, and the patient noted dark-colored urine.

Laboratory tests – cytolysis syndrome: AST-374 U/L (N 5-34U/L), ALT- 1072 U/L (N 0- 55U/L); cholestasis: Alkaline phosphatase - 153 U/L (N 46-116U/L), γ-glutamyl transpeptidase 121 U/L (N 5-55 U/L), BT -5.5 mg/dl (N: 0.2-1.2 mg/dl); BD- 3.8 mg/dl (N:

0-0.2 mg/dl); normal complete blood cound and lipase. The urine test was positive for bilirubin.

Ultrasound examination:

Fig 6.1 Fig 6.2

Fig 6.3 Fig 6.4

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25 Fig. 6.5 A-D

Fig 6.5.A - distended main bile duct with a diameter of 13-14 mm;

Fig 6.5.B - cholecystolithiasys – multiple gallstones (hyperechoic images with acoustic shadowing) and biliary sludge;

Fig 6.5.C - dilated intrahepatic biliary ducts;

Fig 6.5.D - distended common bile duct and choledocholithiasis (small stone in the common biliary duct – CBD).

The patient has undergone ERCP that showed an enlarged main biliary duct with a filling defect at this level. Sphincterotomy and gallstone extraction was performed.

After ERCP, the general condition improved with the remission of jaundice and normalization of laboratory tests.

On discharge, the patient was refferred to surgerry for cholecystectomy.

Discussion

Patients with jaundice should be examined by abdominal ultrasound on presentation.

Ultrasound can differentiate among obstructive jaundice and hepatocellular jaundice in almost all patients.

Ultrasound is highly sensitive for the diagnosis of gallbladder stones (sensitivity-98%), whereas choledocholithiasis is more difficult to detect (sensitivity-65-75%) [1,2].

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ERCP (endoscopic retrograde cholangiopancreatography) with endoscopic sphincterotomy, including stone extraction using baloon or Dormia basket, is the therapeutic method of choice in patients with obstructive jaundice due to choledocholithiasis.

Final diagnostic: Obstructive jaundice due to choledocholithiasis.

References:

1. Cooperberg PL, Burhenne HJ. Real-time ultrasonography. Diagnostic technique of choice in calculous gallbladder disease. N Engl J Med. 1980; 302:1277-1279.

2. Dietrich CF, Gouder S, Hocke M, et al. Endoscopic Ultrasound in the Differential Diagnosis of Choledocholithiasis. Endo heute 2004; 17(3): 160-166.

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Case 7 Liver (B)

History: a 70 years-old-male was admitted in our department with fever, shiver, nausea, jaundice and abdominal pain.

Laboratory findings revealed:

o leucocytosis 17.400 /microL [4000-900/microL],

o elevated liver function tests AST: 109 U/L [5-45], ALT: 123 U/L [5-55], T.bil: 5.86 mg/dL [0-1.2], D.bil: 5.189 mg/dL [0-0.3], ALP: 550 U/L [35-104], GGT: 880 U/L [7- 50],

o inflammatory markers CPR: 92 mg/l, ESR 77mm/1h, Fibrinogen 621 mg/dl.

Abdominal Ultrasound:

Fig.7.1

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Fig.7.1 Ultrasound reveals an inhomogenous hepatic lesion of approximatelly 7 cm in diameter in the right hepatic lobe, segment VIII, with mixed, liquid-solid appereance.

Possible diagnoses:

o liver abscess – considering the clinical data;

o liver hematoma - less likely (no history of trauma) o cystic tumor.

Contrast enhanced ultrasound (CEUS) was performed (Fig. 7.2 A-D), which revealed

Fig.7.2. CEUS (A-D)

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Fig. 7.2.A: Standard US inhomogenous hepatic lesion of approximatelly 7 cm in diameter in the right hepatic lobe, segment VIII, with mixed, liquid-solid appereance, suggestive for liver abcess;

Fig.7.2.B: CEUS - arterial phase: isoenhancement of the lesion as compared with the surrounding liver with unenhancing areas - honeycomb appereance;

Fig. 7.2.C: CEUS - portal phase - septa enhancement with honeycomb appereance;

Fig. 7.2.D: CEUS - late phase - honeycomb appereance with discrete washout.

Considering the clinical setting, the B-mode ultrasound aspect and the CEUS aspect, the final diagnosis was liver abscess.

A drainage system was installed unde US guidance, antibiotherapy was started, and the evolution was favourable.

Discussion

 In this situation, in a clinical context, Contrast enhanced ultrasound (CEUS) established the diagnosis of liver abscess with the typical honeycomb appereance in the arterial phase with isoenhancement in portal phase and discrete wash-out in the late phase.

 Usually, the positive diagnosis is established based on cross sectional imaging techniques: contrast enhanced CT or MRI, but lately with the introduction of contrast medium in ultrasonography, CEUS has become the modality of choice for diagnosis of liver abscess and also for interventional procedures (abscess aspiration, drainage) [1].

 The differential diagnosis with a necrotic tumor, with a hemorrhagic cyst or with a hematoma might be sometimes challenging.

 CEUS is an important tool in the management of liver abscesses, improves the detection of even small lesions, thus being very useful for the correct evaluation of disease extension.

 Also, the direct intracavitary injection of contrast agent allows confirmation of a correct positioning of a drainage system and the comunication of the cavities inside the abscess [2].

Final diagnostic: Liver Abscess

References:

1. Ignee A, Schuessler G, Cui XW, Dietrich CF. Intracavitary contrast medium ultrasound – different applications, a review of the literature ad future prospects. Ultraschall Med 2013; 34: 504-525.

2. Ignee A, Jenssen C, Cui XW, Schuessler G, Dietrich CF. Intracavitar contrast-enhanced ultrasound in abscess drainage– feasibility and clinical value. Scand J Gastroenterol 2016; 51: 41-47.

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Case 8 Liver (B)

History: a 35-year-old male patient, asymptomatic, with no relevant history, was reffered to the Department of Gastroenterology for reasseement of a focal liver lesion of unknown etiology detected at a previous ultrasound examination.

The clinical examination did not reveal any abnormalities.

Laboratory tests were normal, except Anti-Echinococcus antibodies that were positive.

An abdominal ultrasound examination was performed (Fig. 8.1).

Fig. 8.1

Fig. 8.1. Abdominal ultrasound revealed a hypoechoic, inhomogeneous lesion in the right liver lobe, 6/5 cm in diameter, with a well-defined wall. The ultrasound aspect raised the suspicion of hydatid cyst.

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We performed contrast enhanced ultrasound (CEUS) to characterize the liver lesion, knowing that the hydatid cyst is an avascular lesion.

CEUS examination:

Fig. 8.2

Fig. 8.2 - CEUS examination showed the absence of contrast enhancement during the arterial phase. The lesion remained unenhanced during portal and late phases and confirmed the diagnostic of a hydatid cyst.

Discussion

 Ultrasound and CEUS are useful in diagnosing liver echinococcosis in all stages, providing valuable information for further management.

 Gharbi et al. first introduced the classification of hydatid liver disease based on the ultrasound appearance:

- Type I: pure cystic fluid collection (spherical-ova, thick-walled);

- Type II: fluid collection with detached membranes;

- Type III: fluid collection with septa, multiple septa, ,,rosette-like”; ,,honeycomb”

cyst; cyst with daughter cysts in a solid matrix;

- Type IV: heterogeneous (hypoechoic-hyperechoic-intermediate) pattern;

- Type V: calcified walls.

Final Diagnostic: Hydatic cyst type IV (Gharbi)

Reference:

1. Gharbi HA, Hassine W, Brauner MW, Dupuch K. Ultrasound examination of the hydatic liver. Radiology 1981;139(2):459-63.

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Case 9 Liver (B)

History: a 65-year-old male patient admitted in the Department of Gastroenterology for severe pain in the left lower quadrant;

• for 2 months abdominal tenderness, weigth loss, constipation, fatigue, and

• minor rectal bleeding 1 months ago;

• personal medical history – arterial hypertension managed with telmisartan;

Laboratory findings: anemia (Hb=9.8 g/dl); AST=86 UI/L; ALT= 105 UI/L; BT= 4.5 mg/dl

Colonoscopy: revealed a rectal tumor, biopsies were taken that revealed an adenocarcinoma

Ultrasound examination (Fig. 9.1)

Fig. 9.1

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Fig. 9.1. Abdominal ultrasound findings were - multiple hyperechoic focal liver lesions with hypoechoic halo sign (target lesions) with various sizes.

 Based on the clinical data, history, biology, the suspected diagnosis was of liver metastases secondary to colonic cancer.

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Contrast enhanced ultrasound (CEUS) was performed for further characterization of the lesions (Fig. 9.2 A, B, C).

Fig. 9.2.A Fig. 9.2.B

Fig. 9.2.C

Fig. 9.2.A arterial phase - the lesions are hyperenhancing as compared with the surrounding liver parenchyma.

Fig. 9.2.B portal phase - early washout starting 45 sec after contrast bolus.

Fig. 9.2.C late phase – the lesion show obvious washout.

CEUS conclusion: hypervascular liver metastases.

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Discussion

 CEUS has improved the diagnosis of liver metastasis and is an excellent imaging method for the vascular pattern characterization [1].

 CEUS has similar performance to CT and MRI for diagnosing liver metastases. The dual blood supply of the liver permits detection and characterization of focal liver lesions based on vascular enhancement patterns.

 CEUS improves the diagnosis of metastases in patients with a history of colorectal cancer who are undergoing surveillance.

 CEUS can differentiate venous thrombosis from tumor infiltration of hepatic vessels [2].

Final diagnostic: Hypervascular liver metastases.

References:

1. Claudon M, Dietrich CF, Choi BI, et al. Guidelines and good clinical practice recommendations for contrast enhanced ultrasound (CEUS) in the liver--update 2012: a WFUMB-EFSUMB initiative in cooperation with representatives of AFSUMB, AIUM, ASUM, FLAUS and ICUS. Ultraschall Med 2013;34:11-29.

2. https://www.uptodate.com/Contrast-enhanced ultrasound for the evaluation of liver lesions.

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Case 10 Liver (B)

History: a 45-year-old male patient, admitted in emergency for upper digestive hemorrhage.

Clinical exam: Pale, hypotensive patient, BP 90/50 mmHg, AV 110 beats/min

Laboratory findings:

o severe anemia (Hb 6 g%)

o cytolysis – AST 3xUVN, ALT 3xUVN, GGTP – 6xUVN, alkaline phosphatase normal, Total bilirubin 1.5 mg%, INR -1.

Upper digestive endoscopy: bleeding grade 3 esophageal varices – hemostasis by band ligation was performed in emergency

Transient elastography by FibroScan – 55 kPa

Abdominal ultrasound evaluation: - Fig. 10.1, 10.2

Fig. 10.1 Fig. 10.2

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37

Fig. 10.1 Fig. 10.2

Fig. 10.1. and Fig. 10.2. A large hyperechoic, homogenous, “clover-like” lesion surrounding the gallbladder, well delineated, with no mass-effect on the gallbladder.

Possible diagnoses:

o Hemangioma (hyperechoic homogenous lesion).

o Hepatocellular carcinoma (newly discovered lesion in a cirrhotic patient).

o Focal fatty infiltration (hyperechoic, homogenous lesion surrounding the gallbladder, well delineated, with no mass-effect).

Contrast enhanced ultrasound was performed for the differential diagnosis.

Fig. 10.3. Fig. 10.4.

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Fig. 10.5

Fig. 10.3 CEUS - arterial phase: the lesion is iso-enhancing.

Fig. 10.4 CEUS – portal phase: the lesion is iso-enhancing.

Fig. 10.5 CEUS – late phase: the lesion is iso-enhancing.

CEUS final diagnosis - focal fatty infiltration.

Discussion

 When a new focal lesion is found in a cirrhotic liver, the first suspicion should be hepatocellular carcinoma. In CEUS, HCCs are hyperenhancing in the arterial phase and show washout, usually in the late phase [1]. The more well differentiated the HCC, the latter the washout [2].

 Due to the hyperechoic, well-delineated homogenous aspect, another suspicion is of a hemangioma, which has a typical enhancement pattern on CEUS, with nodular centripetal enhancement that starts in the arterial phase and progresses in the portal and late phases [1].

 However, the lesion found in our patient showed no invasion and no mass-effect on the gallbladder it surrounded, thus being less likely to be a liver tumor (benign or malignant).

 The diagnosis of Focal Fatty Infiltration was made by CEUS, and confirmed by MRI (Fig.

10.6).

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39

Additional Imaging

Fig. 10.6

Fig. 10.6. MRI – homogenous structure of the liver, no FLL surrounding the gallbladder Follow-up at one year (the patient stopped drinking) showed no lesion in the liver by abdominal ultrasound.

Final diagnosis: Focal Fatty Infiltration.

References:

1. Claudon M, Dietrich CF, Choi BI et al. Guidelines and good clinical practice recommendations for contrast enhanced ultrasound (CEUS) in the liver: update 2012—a WFUMB-EFSUMB initiative in cooperation with representatives of AFSUMB, AIUM, ASUM, FLAUS and ICUS. Ultraschall Med 2013;

34:11–29.

2. Boozari B, Soudah B, Rifai K, et al. Grading of hypervascular hepatocellular carcinoma using late phase of contrast enhanced sonography - a prospective study. Dig Liver Dis 2011;43:484-490.

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Case 11 Liver (B)

History: a 66 years old man, without any important medical history was referred to our Department with the suspicion of alcohol induced hepatic cirrhosis, complicated with hepatocellular carcinoma (HCC).

Biology: mild anemia (Hb: 11.2 g/dl); elevated liver enzymes (AST: 2XUVN, ALT:

1.5XUVN, GGT: 5XUVN); AFP: normal value.

Transient elastography by Fibroscan: 50.5 kPa.

Upper digestive endoscopy: no pathological findings.

Abdominal ultrasound: Fig. 11.1, Fig. 11.2.

Fig.11.1

Fig. 11.2

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41

Abdominal Ultrasound: Fig. 11.1- 11.2

Fig. 11.1 Fig. 11.2

Fig. 11.1 and 11.2 - the liver has an heterogeneous structure with irregular margins, typical findings in a cirrhotic patient. A hyperechoic lesion with a hypoechoic rim was described in the right liver lobe, in segment IV, measuring 3 cm.

Possible diagnosis:

o hemangioma (hyperechoic, homogenous lesion);

o hepatocellular carcinoma (newly discovered lesion in a cirrhotic patient);

o liver metastasis (hypoechoic rim).

Contrast enhanced ultrasound (CEUS) was performed, for the differential diagnosis (Fig 11.3-11.4).

Fig. 11.3

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Fig. 11.4

Fig. 11.3 - in the arterial phase - peripheral nodular enhancement with centripetal filling;

Fig.. 11.4 - isoechoic aspect in the portal venous phase and delayed phase; no „wash out”

was observed during the examination.

The conclusion of the examination was: atypical hemangioma.

Discussion

 Haemangioma is the most common benign tumor in the liver. Haemangiomas typically appear as hyperechoic, well defined lesions. However, when the features are atypical at conventional ultrasound, further investigation is required, especially when the lesion appears in a cirrhotic patient [1].

 In a cirrhotic liver, any new focal liver lesion should be highly suspicious for HCC, thus a contrast imaging method is needed for a final diagnosis.

 Later the diagnosis was confirmed by MRI exam.

Final diagnosis: Liver hemangioma.

Reference:

1. Huang M, Zhao Q, Chen F, You Q, Jiang T. Atypical appearance of hepatic hemangiomas with contrast- enhanced ultrasound. Oncotarget. 2018;9(16):12662‐12670. doi:10.18632/oncotarget.24185

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Case 12 Liver (A)

History: a 64 year old man, known with chronic hepatitis B from 2010, at present being under treatment with Entecavir, presented to the emergency room complaining of pain in the right upper quadrant, malaise, weight loss and rectal bleeding.

Clinical exam:

o BP was 140/80 mmHg, HR=70 beats/minute

o abdominal pain in the right upper quadrant, spontaneously and on palpation;

o rectal bleeding

Laboratory findings revealed:

o Hypochrome, microcytic anemia - Hb=10.5 g/dl

 A flexible sigmoidoscopy was performed revealing a stenosing sigmoid tumor and biopsies were taken.

Abdominal ultrasound revealed the following aspect (Fig.12.1-12.3)

Fig. 12.1. Fig. 12. 2

Fig. 12.3

\

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Abdominal ultrasound (Fig. 12.1-12.3)

Fig. 12.1 Fig. 12.2

Fig. 12.3

Fig.12.1 - a large hyperechoic mass (10 cm) occupying the segments V, VI, VIII of the liver, with no evidence of vascular involvement;

Fig.12.2 - another isoechoic tumor of 3 cm near the portal bifurcation;

Fig.12.3 - two similar tumors in the left liver lobe of 6 and 2 cm respectively.

The caudate lobe was les than 35 mm and the spleen was 10 cm in length.

Possible diagnoses at this moment

 Considering the chronic hepatitis B history – possible hepatocellular carcinoma;

 Considering the stenosing sigmoid tumor – possible metastases.

Contrast enhanced ultrasound was performed (Fig. 12.4-12.6), which revealed the following aspect:

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45 Fig. 12.4

Fig. 12.5

Fig. 12.6

Fig. 12.4 CEUS - arterial phase, the large hyperechoic lesion occupying the segments V, VI, VIII of the liver is hyperenhancing.

Fig. 12.5 CEUS - portal phase, the large hyperechoic lesion occupying the segments V, VI, VIII of the liver is isoenhancing.

Fig. 12.6 CEUS - late phase, the large hyperechoic lesion occupying the segments V, VI, VIII of the liver shows a slight wash-out.

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Based on CEUS we could exclude liver metastasis (much earlier and intense „wash-out”).

Possible diagnoses in this stage - hepatocellular carcinoma and less likely hepatocellular adenomas (newly developed lesions).

Additional Imaging

An MRI with liver specific contrast was performed (Fig. 12.7-12.10), showing a central scar composed of fibrous tissue (compatible with a cholangiocarcinoma)

Fig. 12.7 Fig. 12.8

Fig. 12.9 Fig. 12.10

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47

Fig. 12.7-12.10 – Hepatic tumour with central scar and fibrotic bands in T2FatSat

(Fig.12.7),axial contrast-enhanced MRI T1 FS(VIBE) image in arterial phase shows that tumours (yellow arrows) are hyperattenuating compared with liver parenchyma (Fig.12.8), portal phase shows that tumours are isoattenuating (yellow arrows) compared with adjacent liver

parenchyma. Central scar does not show any enhancement ( bold yellow arrow) (Fig.12.9) Axial contrast-enhanced MRI T1 is now hypoattenuating with enhancement of the capsule (yellow arrow). Central scar does not show any enhancement (bold yellow) (Fig.12.10)

 Finally, a core biopsy was performed, which confirmed the diagnosis of fibrolamellar HCC, while the tumour in the sigmoid was a tubulo papillary adenocarcinoma (pT3N1bLV1R0).

Discussion

 The diagnosis of fibro-lamellar carcinoma may not be suspected until radiological imaging or histopathological examination is done.

 Hepatocellular carcinomas are malignant liver lesions that appear in cirrhotic patients.

 Fibro-lamellar hepatocellular carcinoma is a rare type of malignant liver tumor which occurs most often in young adults without an underlying liver disease, usually with normal serum levels of alpha-fetoprotein [1].

 Frequently it appears as a single mass and the diagnosis is suggested by imaging findings (CT scans or MRI), and confirmed by histology.

 The particularity of this case was the presence of multiple fibro-lamellar lesions in an elderly patient with underlying chronic HBV hepatitis and underlying non-liver neoplastic disease (adenocarcinoma of the sigmoid colon).

Final diagnosis: Fibrolamellar hepatocellular carcinoma.

Reference:

1. Titelbaum DS, Burke DR, Meranze SG, et al. Fibrolamellar hepatocellular carcinoma: pitfalls in nonoperative diagnosis. Radiology. 1988 Apr;167(1):25-30.

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Case 13 Liver (A)

History: a 49 year old woman, asymptomatic, without no other known pathology and with no use of contraceptives, presented to the emergency room complaining of a sudden-onset right upper quadrant pain, as well as right lower quadrant pain.

Clinical exam:

o BP was 130/80 mmHg, HR=70 beats/minute

o abdominal pain in the right hypochondrium, spontaneously and on palpation;

Laboratory findings revealed:

o Leucocytosis - 13300/mm3

o Normochrome anemia - Hb=10.5 g/dl o AST 476 IU/l, ALT 280 IU/l

Abdominal ultrasound: revealed the follwing aspect (Fig.13.1 and Fig.13.2)

Fig.13.1

Fig.13.2

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49 Abdominal ultrasound (Fig.13.1-13.2)

Fig.13.1

Fig.13.2

Fig.13.1-13.2 Ultrasound B-mode image of the right liver lobe (intercostal section) reveals a large isoechoic inhomogeneous mass (12/8 cm) occupying the segments VIII, VII, VI, and V of the liver (Fig.13.1), and a hypoechoic lesion, 2.7 cm in diameter in segment VI (Fig.13.2)

Possible diagnosis:

o Liver tumor (benign or malignant) o Liver hematoma

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Contrast enhanced ultrasound was performed, which revealed the following aspect of the larger lesion (Fig.13.3-13.4):

Fig.13.3

Fig.13.4

Fig.13.3-13.4 CEUS - arterial phase the large lesion in segments VIII, VII, VI, and V was non- enhancing as compared with the surrounding tissue (Fig.13.3); late phasethe large lesionwas still unenhancing, but a slight wash-out was visible at the margins of the lesion (Fig.13.4).

 Considering the clinical setting, the B-mode ultrasound aspect and the CEUS aspect a ruptured tumor of the liver was suspected (possible malignant, due to the late „wash- out”).

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51

Additional Imaging

MRI was performed for a definitive diagnosis (Fig.13.5-13.8)

Fig.13.5 Fig.13.6

Fig.13.7 Fig.13.8

Fig.13.5-13.8- MRI of the abdomen was performed that showed a large hematoma (11/5cm) in the middle of hepatocelullar adenoma (arrows) (Fig.13.5-13.6) and multiple nodular lesions sugestive for hepatocelullar adenomas (arrows) (Fig.13.7-13.8)

 Due to the fact that the patient was hemodinamically stable, without haemoperitoneum, we opted for a conservative management. At 3 months the hematoma regressed from 12 to 7 cm, than, at 1 year, to 5 cm (Fig.13.9).

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Fig.13.9

Fig.13.9 US B mode image after 1 year reveals an hyperechoic lesion of 5 cm.

Contrast enhanced ultrasound 1 year after presentation showed the following aspect (Fig.13.10-13.12)

Fig.13.10

Fig.13.11

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53 Fig.13.12

Fig.13.10-13.12 - CEUS after 1 year – arterial phase the lesion is slightly hyperenhancing with the exception of central area that is unenhancing (Fig.13.10), portal phase the

lesions mantains the contrast with the exception of the central area which is unenhancing (Fig.13.11), late phase the lesion is isoenhancing, with the exception of the central area, still unenhancing (Fig.13.12).

Discussion

 Hepatocellular adenoma (HA) is a rare benign tumour of the liver. The lesions most often are seen in young women using oral contraceptives. HA are usually solitary (70- 80% of cases) [1] and large at the time of diagnosis (5-15 cm) [2]. Most patients are clinically asymptomatic but in some cases HAs may rupture and bleed, causing right upper abdominal quadrant pain. Spontaneous rupture of hepatocellular adenoma is usually a non-life threatening condition, but rarely, rupture may lead to hemorrhagic shock needing emergency treatment. HA can undergo malignant transformation to hepatocellular carcinoma (HCC) [3,4] for this reason surgical resection is advocated in most patients with presumed HAs.

 The particularity of this case is the clinical and biological silent evolution until a brutal complication which, fortunately, had a spontaneous uneventful evolution.

Final diagnostic: Spontaneous intrahepatic rupture

of a hepatocellular adenoma.

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References:

1. Faria SC, Iyer RB, Rashid A et-al. Hepatic adenoma. AJR Am J Roentgenol. 2004;182 (6): 1520.

2. McGahan JP, Goldberg BB. Diagnostic ultrasound. Informa Health Care. (2008)

3. Gyorffy EJ, Bredfeldt JE, Black WC et al. Transformation of hepatic cell adenoma to hepatocellular carcinoma due to oral contraceptive use. Ann Intern Med. 1989;110:489–490.

4. Neuberger J, Portmann B, Nunnerly HB et al. Oral contraceptive-associated liver tumors: occurrence of malignancy and difficulties in diagnosis. Lancet. 1980;1:273–276.

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Case 14 Liver (A)

History: a 75 years old female patient presents in the emergency room complaining of pain in the base of the right hemithorax, fever 38-39 C at home, chills, fatigue. Medical history reveals essential arterial hypertension and previous hospitalization for bacterial pneumonia three weeks ago.

Chest X-ray was normal.

Lab tests show leukocytosis, inflammatory syndrome, and cytolytic syndrome.

An abdominal ultrasound examination was performed.

Fig 14.1

Fig 14.2

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Fig. 14.1

Fig. 14.2

Fig. 14.1. and Fig 14.2. The Ultrasound examination shows in the right liver lobe, segment IV, a hypoechoic focal liver lesion of 7/8 cm, with an anechoic component, in the context of a liver with moderate steatosis.

Contrast enhanced ultrasound (CEUS) was performed (Fig. 14.3 A, B, C), which revealed:

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57

Fig 14.3(A-C) CEUS

Fig. 14.3. A - shows in the arterial phase a hyperenhancing pattern in the periphery of the hepatic lesion but also at the level of the septa, suggesting a "honeycomb" pattern.

Fig. 14.3. B, C - In the venous (B) and late (C) phases a mild washout can be observed in the hyperenhancing areas.

In the clinical and paraclinical context, the suspicion of liver abscess was raised. To confirm the diagnosis, we performed an ultrasound guided puncture of the lesion with extraction of 2 ml of pus.

The culture of the aspirated liquid showed a purulent collection with Escherichia coli.

Initially, we started treatment with a wide spectrum antibiotic, afterward adjusted according to the antibiogram with a favorable clinical evolution. The patient became afebrile, and the inflammatory biological syndrome improved. During hospitalization, the abscess did not evolve to a collection suitable for percutaneous drainage. The patient was discharged with the recommendation to continue antibiotic treatment for up to 4 weeks, with uneventful evolution during follow-up.

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Discussion

 Biliary tract obstruction is the most common source of pyogenic liver abscess.

Abdominal infection, such as appendicitis, diverticulitis, or a perforated bowel can also be cause for liver abscess. Many liver abscesses are cryptogenic and frequently associated with chronic medical conditions such as diabetes mellitus.

 Conventional ultrasound has 85 to 96% sensitivity for detecting pyogenic liver abscesses. In CEUS examination, the presence of rim enhancement in the arterial phase, septa enhancement (honeycomb appearance), no enhancement in the liquid-necrotic areas, and venous hypoenhancement are the most common features of liver abscesses.

 US-guided aspiration is required for a definite diagnosis and also obtains a sample for microbiology. The proper treatment of liver abscesses includes wide-spectrum antibiotics, percutaneous aspiration, percutaneous drainage, or surgical drainage.

Final diagnostic: Liver abscess

References:

1. Mavilia MG, Molina M, Wu GY. The Evolving Nature of Hepatic Abscess: A Review. J Clin Transl Hepatol. 2016;4(2):158-68.

2. Cai YL, Xiong XZ, Lu J, et al. Percutaneous needle aspiration versus catheter drainage in the management of liver abscess: a systematic review and meta-analysis. HPB (Oxford). 2015;17(3):195-201 3. Claudon M, Cosgrove D, Albrecht T, et al. Guidelines and good clinical practice recommendations for contrast enhanced ultrasound (CEUS) – update 2008. Ultraschall Med 2008; 29: 28-44.

4. Gyorffy EJ, Frey CF, Silva J Jr, McGahan J. Pyogenic liver abscess. Diagnostic and therapeutic strategies.

Ann Surg 1987; 206: 699-705.

5. Mohsen AH, Green ST, Read RC, McKendrick MW. Liver abscess in adults: ten years experience in a UK centre. QJM 2002; 95: 797-802.

6. Popescu A, Sporea I, Șirli R, et al. Does Contrast Enhanced Ultrasound improve the management of liver abscesses? A single centre experience. Med Ultrason 2015, Vol. 17, no. 4, 451-455.

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Case 15 Liver (A)

History: a 68-year-old female patient, known with HBV compensated liver cirrhosis under treatment with Entecavir for three years with PCR AND HBV undetectable. The patient came to our department for a surveillance ultrasound examination.

FibroScan = 49 kPa.

Lab tests showed pancytopenia, hypoalbuminemia, and AFP= 145 ng/ml.

Ultrasound examination:

Fig 15.1

Fig 15.2

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Fig. 15.1 - hyperechoic material inside the portal vein (arrow) – portal thrombosis?

Fig 15.2 - partial absence of flow inside the right portal branch – no Doppler signal in the thrombus area.

Contrast enhanced ultrasound (CEUS) was performed for further characterization (Fig 15.3 A, B).

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61

Fig 15.3.A, B - CEUS: thrombus enhancement is absent in arterial (A) and late (B) phase.

This pattern confirms the benign nature of the thrombosis.

Discussion

 Portal vein thrombosis (PVT) is a frequent complication of liver cirrhosis, and its prevalence increases with the severity of liver disease and is most often associated with hepatocellular carcinoma (HCC). Patients with liver cirrhosis and hepatocellular carcinoma can have malignant or benign PVT.

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CEUS is a very sensitive method for the differential diagnosis between benign and malignant PVT. Blunt thrombi are avascular and will not enhance during CEUS examination, while a hyperenhancement pattern of portal thrombus in the arterial phase, with “wash out” in the portal or late phase, is typical for malignant PVT.

Final diagnostic: Partial benign portal vein thrombosis.

References:

1. Danila M, Sporea I, Popescu A, et al. Portal vein thrombosis in liver cirrhosis - the added value of contrast enhanced ultrasonography. Med Ultrason. 2016 Jun;18(2):218-33.

2. Chammas MC, Oliveira AC, D Ávilla MJ, et al. Characterization of Malignant Portal Vein Thrombosis with Contrast-Enhanced Ultrasonography. Ultrasound Med Biol. 2019;45(1):50-55.

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63

Case 16 Liver (A)

History: a 32-year-old female patient with no medical history was complaining about intermittent abdominal pain in the upper right abdominal quadrant presented in the department of Gastroenterology for abdominal ultrasound evaluation.

Lab tests - normal liver enzymes, AFP; negative serum markers for hepatitis viruses.

Ultrasound examination:

Fig 16.1

Fig 16.2

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Ultrasound examination:

Fig 16.1 - hypoechoic focal liver lesion in the right liver lobe of 7.5/6 cm.

Fig. 16.2 – Spoke-wheel pattern blood flow detected in colour Doppler mode.

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65

Contrast enhanced ultrasound (CEUS) was performed for further characterization. (Fig.

16.3 A, B, C).

Fig. 16.3. A - arterial phase - the tumor has a rapid, complete, centrifugal arterial hyperenhancing; unenhanced central scar;

Fig. 16.3. B - portal phase - hyperenhancing tumor, unenhanced central scar;

Fig. 16.3. C - late phase - iso/hyperenhancing lesion; no washout; unenhanced central scar.

The CEUS enhancement pattern is typical for focal nodular hyperplasia [1, 2, 3].

Discussion

Focal nodular hyperplasia (FNH) is the second most common benign liver lesion.

Frequent, it is incidentally discovered during a routine ultrasound examination since the majority of cases with focal nodular hyperplasia are asymptomatic. CEUS can be used as a good alternative method for the rapid diagnosis of FNH.

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A recent study showed that CEUS is a feasible approach for the diagnosis of focal nodular hyperplasia with similar performance to MRI [1].

Final diagnostic: Focal nodular hyperplasia (FNH).

References:

1. Negrão de Figueiredo G, Mueller-Peltzer K, Schwarze V, et al. Long-term study analysis of contrast- enhanced ultrasound in the diagnosis of focal nodular hyperplasia. Clinical Hemorheology and Microcirculation. 2019 Nov. DOI: 10.3233/ch-190710.

2. Venturi A, Piscaglia F, Vidili G, et al. Diagnosis and management of hepatic focal nodular hyperplasia. J Ultrasound. 2007;10(3):116‐127. doi:10.1016/j.jus.2007.06.001.

3. Claudon M, Dietrich CF, Choi BI, et al. Guidelines and good clinical practice recommendations for contrast enhanced ultrasound (CEUS) in the liver--update 2012: a WFUMB-EFSUMB initiative in cooperation with representatives of AFSUMB, AIUM, ASUM, FLAUS and ICUS. Ultraschall Med 2013;

34:11-29.

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67

Case 17 Liver (A)

History: a 66 years-old-male was admitted in our department with malaise, fever up to 38.7 °C , abdomial pain, predominantly in the right hypochondrium. The onset was approximately two weeks before presentation, with progressive worsening.

Clinical exam:

o poor general state, uncooperative, drowsy patient o jaundiced sweaty skin, parched tongue

o BP 80/60 mmHg, AV 100 b/min

o abdominal pain in the right hypochondrium, spontaneously and on palpation;

hepatomegaly with the inferior margin of the liver 4 cm below the ribs

Laboratory findings revealed:

o Increased liver function test - AST: 289 U/L [5-45], ALT: 236 U/L [5-55], T.bil: 3.9 mg/dL [0-1.2], ALP: 432 U/L [35-104], GGT: 195 U/L [7-50].

o Leucocytosis with neutrophylia - 12700/mm3, neutrophyles 95.2%

o Normochrome anemia - Hb=11 g/dl o Hypoalbuminemia - Albumins=1.6 g/dl

Abdominal ultrasound:

Fig. 17.1 Fig. 17.2

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Fig. 17.1 Fig. 17.2

Fig. 17.1 and 17.2 : In the segments VII and VIII of the liver, a slightly hyperechoic poorly delineated large lesion, approximately 10/8 cm, with anechoic areas inside.

Possible diagnoses:

o liver abscess – considering the clinical data;

o liver hematoma: less likely – no history of trauma o cystic tumor.

Contrast enhanced ultrasound was performed, which revealed the following aspect:

Fig. 17.3 Fig. 17.4

Fig. 17.3 CEUS: Arterial Phase - Enhancing lesion, with unenhanced center.

Fig. 17.4 CEUS: Late phase - The rim of the lesion is slightly hypoenhancing and the central part is still unenhancing.

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69

Considering the clinical setting, the B-mode ultrasound aspect and the CEUS aspect, the final diagnosis was Liver Abscess.

Ultrasound guided aspiration was performed and puss was extracted, thus confirming the diagnosis. Culture from the aspirate was positive for Klebsiella pneumoniae sensitive to Cefepime, Ertapeneme, Meropeneme, Imipeneme. Treatment with Ertapenem 2x 250 mg/day was started and, after an initial acute renal failure (creatinine 9mg%) treated conservatively, the outcome was favorable with complete remission.

Discussion

 The incidence of liver abscess is slightly increasing (4.1: 100,000), with a mortality of 3- 30% (higher in the elderly, in patients with organ deficiency) [1]. There are three major forms of liver abscesses, classified by etiology: pyogenic abscesses, more than 80% of the cases; amoebic abscesses (caused by Entamoeba histolytica, approximately 10% of cases); and fungal abscesses, most commonly due to Candida, less than 10% of cases.

 The treatment of liver abscesses is made by ultrasound or CT guided percutaneous drainage associated with antibiotic therapy [2, 3]. Surgical drainage or resection associated with antibiotic therapy is needed in patients with ruptured abscess and secondary peritonitis; in large multiloculated abscesses (5 cm); which do not respond to percutaneous drainage and antibiotic therapy [2, 4].

Final diagnosis: Liver Abscess.

References:

1. Meddings L, Myers RP, Hubbard J, et al. A population-based study of pyogenic liver abscesses in the United States: Incidence, mortality, and temporal trends. Am J Gastroenterol 2010 Jan; 105:117.

2. Hope WW, Vrochides DV, Newcomb WL et al: Optimal treatment of hepatic abscess. An Surg.2008;74:178-182.

3. Liu CH, Gervais DA,Hahn PF, et al. Percutaneous hepatic abscess drainage: do multiple abscesses or multiloculated abscesses preclude drainage or affect outcome? Vasc Interv Radiol.2009;20:1059-1065.

4. Chung YF, Tan YM, Lui HF, et al. Management of pyogenic liver abscesses - percutaneous or open drainage? Singapore Med J.2007;48:1158-1165.

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Case 18 Liver (A)

History: a 77-year-old patient with Gaucher disease undergoing enzyme replacement therapy with a history of left renal cancer (left nephrectomy and splenectomy 7 years ago) performs a routine check-up.

Biology: Laboratory tests showed a normal hemoglobin level, normal transaminases, no cholestasis and no other changes except a slightly elevated serum AFP level (24 ng/ml) and a high level of ferritin (823 µg/l).

Abdominal ultrasound (Fig.18.1-18.3)

Fig.18.1 Fig.18.2

Fig.18.3

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71

Abdominal ultrasound (Fig.18.1-18.3)

Fig.18.1 Fig.18.2

Fig.18.3

Fig.18.1-18.3 - Homogenous liver, in segment 7 of the liver a focal hyperechoic lesion of approximately 4/3.7 cm in size, newly developed.

Possible diagnoses:

o Gaucheroma

o Benign liver tumor (less likely due the fact that is a new lesion in an elderly man) o Liver metastasis (history of renal cancer)

o Hepatocellular carcinoma (HCC).

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Contrast enhanced ultrasound was performed: (Fig. 18.4-18.5).

Fig.18.4 Fig.18.5

Fig.18.4-18.5 CEUS- the lesion was hyperenhancing in the arterial phase, completely enhanced at 20 sec (Fig. 18.4), followed by wash out in the portal phase which becomes evident in the late phase (Fig 18.5).

Diagnosis following CEUS – malignant lesion (either metastasis, or hepatocellular carcinoma).

Additional Imaging

Liver transient elastography (FibroScan) was performed - liver stiffness median of 7.7 kPa, corresponding to significant fibrosis (F=2 Metavir).

Contrast enhanced CT scan was performed, revealing in the hepatic segment VII, in contact with the posterior wall of the right hepatic vein, a hypervascularized lesion in the arterial phase with central necrosis, enhancing from the periphery towards the center but with peripheral wash-out in the late phase. The aspect is suspicious for malignancy, but it could not differentiate between metastasis or HCC (Fig. 18.6).

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