focal nodular hyprplasia FNH case PRESENTATION

TEHELKA CASE

PATIENT HISTORY

• A 40year old woman presenting to EMERGENCY with vague pain in abdomen and hypotension with acute onset. No significant previous history.

NEGATIVE HISTORY

• No fever, chills, or significant weight loss

• Patient denies history of blood transfusions, OC pills, tattoos, IV drug use, HIV, or significant alcohol intake, trauma.

• No DM or hypertension.

OBJECTIVE EXAMINATION

• Pallor (+).

• No lymphadenopathy, icterus , clubbing.

• No organomegaly.

• Guarding (+) and s/o intra peritoneal collection on palpation.

• Nothing significant on auscultation.

• Bowel sounds (+)

LAB TESTS

• WHAT ALL WOULD YOU ORDER???

• CBC unremarkable Except Hb < 10.

• AFP Normal

• Hepatitis A and B serology negative

• Carcinogenic Embryonic antigen normal

• Liver and renal function tests unremarkable

• Amylase normal

• UPT –VE.

Differentials on this history ??

What next ???

RADIOLOGIST PATA LAGAO…

YE CASE KYA HAI

BED SIDE USG• Large heterogeneous mixed echogenic lesion

in left lobe of liver measuring about 10.5 x 6 x 9 cms. No calcification noted in the lesion. Rest of the liver parenchyma normal. No other focal lesion. Portal vein and intra hepatic biliary radicles normal.

• Significant collection in peritoneum which was HAEMORHAGIC ON tap.

• Bilateral pleural effusion

• Uterus, adnexa clear. IUCD noted IN SITU.

DIFFERENTIALS ???

On USG

• STILL A RUPTURED ECTOPIC ???

BUT UPT –VE.

• ?? HEPATIC TUMOR WITH RUPTURE

• OTHER CAUSES…….

CT SCAN

CT FINDINGS• Hepatomegaly. Large well defined iso-hypodense

encapsulated lesion with a hyperdense foci and showing heterogeneous enhancement occupying nearly the entire left lobe measuring 11 x 10 x 6 cms. Small exophytic component noted abutting the adjacent stomach and pancreas with well defined planes. Rest of the liver parenchyma normal.

• Portal vein and biliary radicles normal.

• Moderate ascites

• Bilateral pleural effusion.

FOLLOW UP CT AFTER 20 DAYS

FOLLOW UP CT FINDINGS

• Compared to previous CT there is resolution of bilateral basal pleural effusion and complete resolution of the ascites. The liver does not show any significant change in the size. The hyperdense areas seen on previous CT are not seen on the present study

D/D

• General imaging differential considerations include

– hepatic adenoma

– hepatocellular carcinoma (HCC)

– fibrolamellar HCC

– hyper vascular hepatic metastasis(es)

– hepatic haemangioma

MR in FNH• MRI is both sensitive (70%) and specific (98%).

• T1

– iso to somewhat hypo intense

– hypo intense central scar

• T2

– iso to somewhat hyperintense

– hyperintense central scar

• T1 C+ (Gd) :

– following gadolinium enhancement is similar to CT

– intense early arterial phase enhancement

– iso intense to liver on portal venous phase

– central scar retains contrast on delayed scans

• T1 C+ (hepatobilliary contrast) : demonstrates enhancement

NUCLEAR MEDICINE

• Detection of Kupffer cells in FNH has historically been achieved using technetium-99m (99m Tc) sulfur colloid scanning.

• In 60-70% of FNH patients, these scans show normal or increased uptake of99m Tc sulfur colloid.

TREATMENT IN FNH ??

• WAIT AND WATCH

• ABLATION

• EMBOLIZATION

• EXCISION …????

• THE BALL IS IN YOUR COURT NOW…….