Atypical focal nodular hyperplasia of the liver

BACKGROUND:Focal nodular hyperplasia,a benign hepatic tumor,is usually asymptomatic.However,rarely the entity can cause symptoms,mandating intervention. METHOD:We present a case of focal nodular hyperplasia of the liver,which caused a considerable diagnostic dilemma due to its atypical presentation. RESULTS:A 29-year-old woman presented with a 15-year history of a progressively increasing mass in the right upper quadrant which was associated with pain and emesis. Examination showed a firm,mobile mass palpable below the right subcostal margin.A computed tomography scan of the abdomen showed an exophytic mass arising from hepatic segments III and IVb.Trucut biopsy of the hepatic mass was equivocal.Angiography showed a vascular tumor that was supplied by a tortuous branch of the proper hepatic artery. Surgical intervention for removal of the mass was undertaken. Intra-operatively,two large discrete tumors were found and completely resected.Histopathological examination showed features consistent with focal nodular hyperplasia. CONCLUSION:This description of an unusual case of focal nodular hyperplasia of the liver highlights the point that the diagnosis of otherwise benign hepatic tumors may be difficult despite extensive work-up in some cases.

Partial Splenic Artery Embolization in Cirrhosis Is a Safe and Useful Procedure

Background: Portal Hypertension is a common complication of cirrhosis. It leads to splenomegaly which manifests with features of hypersplenism. This results in leucopenia which increases the likelihood of sepsis and prevents treatment with interferon. Thrombocytopenia increases the risk of bleeding including variceal bleeds which make the anemia worse. This study was done to determine the usefulness and safety of partial splenic artery embolization (PSAE) in portal hypertension due to cirrhosis. Methods: Patients with PSAE were identified by using International Classification of Diseases (ICD)-10 coding from medical records and their charts were reviewed retrospectively. 25 patients underwent splenic artery embolization at The Aga Khan University Hospital Karachi from November 2000 to December 2016. 18 patients who underwent PSAE for disabling hypersplenism caused by cirrhosis were included. Patients who were under 18 year of age, or in whom PSAE were performed for reasons other than cirrhosis and those with missing records/incomplete data were excluded (n = 7). Information was collected regarding demographic details, procedure indications, nature, technique, clinical efficacy, repeat embolization and complications along with laboratory and radiological investigations. Results: Eighteen patients of cirrhosis with a mean age of 43.47 ± 10.926 years, of which 14 were males, underwent PSAE (19 procedures). Indications were severe hypersplenism which precluded treatment with interferon and ribavirin (n = 8) and recurrent Gastro-oesophageal variceal (GOV) bleeds due to advanced Child-Pugh grade and thrombocytopenia (n = 10). Hematological parameters improved significantly following PSAE. Three out of eight patients successfully completed interferon + ribavirin treatment for hepatitis C (HCV) infection post PSAE, and GOV bleeds stopped in eight out of 10 patients. Complications included mild Left upper quadrant (LUQ) abdominal pain n = 9 (47.3%), post-embolization syndrome n = 4 (21%), and clinically insignificant pleural effusion n = 4 (21%). One patient developed spontaneous bacterial peritonitis (SBP) which was appropriately managed. One patient needed re-emobilization after 6 months. Conclusion: PSAE is a safe and effective procedure in the treatment of hypersplenism due to cirrhosis.

Is transarterial embolization a valuable treatment option for spontaneous rupture of hepatocellular carcinoma: experience from a tertiary care hospital of South-Asia

Aim:Transarterial embolization(TAE)has been found beneficial in treatment of ruptured Hepatocellular carcinoma(HCC)in earlier studies.So far no data is available from Pakistan.The aim of this study was to evaluate clinicopathological characteristics,outcomes of patients presented with spontaneously ruptured,unresectable HCC treated with or without TAE and to evaluate the factors associated with 30-day mortality.Methods:This was a cross sectional study.Patients≥18 years old,presented with spontaneous rupture of unresectable HCC,were evaluated.The outcome measures were control of bleeding,in-hospital mortality,30-day mortality and factors associated with 30-days mortality.Results:Out of 850 patients,24 patients were diagnosed with spontaneously ruptured HCC.Mean age was 58.29±15.26 years.A total of 11(45.8%)patients were treated conservatively and 13(54.2%)underwent TAE.Control of bleeding due to ruptured HCC was significantly higher for those treated via TAE as compared to those who were treated conservatively(92.3%vs.36.4%,P=0.008).Overall median duration for which the patients remained alive after HCC rupture was longer for TAE group(39 days vs.5 days,P=0.03).In-hospital mortality(30.8% vs.72.7%,P=0.04)and 30-day mortality was also lower in TAE group(38.5%vs.90.9%,P=0.01).Those who underwent TAE had lower risk of mortality then conservative group odds ratio(OR)0.25,95% confidence interval(CI0.07-0.90,P=0.03).Failure to control bleeding was associated with higher 30-day mortality(OR 2.14,95% CI 1.24-3.68,P=0.009).Conclusion:Ruptured HCC is a life threatening complication requiring early diagnosis and treatment.TAE is an effective and well-tolerated treatment in the management of ruptured HCC.