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Liver abscess or neoplasm? A diagnostic and surgical dilemma

Liver abscess or neoplasm? A diagnostic and surgical dilemma JSCR Journal of Surgical Case Reports http://jscr.co.uk Liver abscess or neoplasm? A diagnostic and surgical dilemma Authors: Hasib Ahmadzai Location: University of New South Wales, Sydney, Australia Citation: Ahmadzai H. Liver abscess or neoplasm? A diagnostic and surgical dilemma. JSCR. 2010. 8:5 ABSTRACT Hepatocellular carcinoma can is often associated with hepatitis B infection.  With localised tumours, liver resection can result in a cure.  This case presents an unusual finding of concurrent hepatitis B and liver fluke infection with hepatocellular carcinoma in a 50 year old man from Thailand.  The discussion illustrates difficulties of arriving at a diagnosis and ensuring appropriate surgical management. INTRODUCTION Hepatocellular carcinoma is known to be strongly associated with hepatitis B infection. This report highlights a rare case of concurrent hepatitis B and liver fluke infection with hepatocellular carcinoma, presenting clinically as a diagnostic and surgical challenge. CASE REPORT A 50 year old male from Thailand presented complaining of right upper quadrant abdominal pain, jaundice, 4kg weight loss over 2 months and hepatomegaly.  His abdominal pain was sharp and intermittent, exacerbated by deep inspiration, although did not radiate and was not associated with eating.  He complained of night sweats and a fever spiking at 40.0°C.  He did not experience nausea, diarrhoea and was able to pass brown stool and clear urine.  He did not have a significant past medical or surgical history, however, his father had died from cholangiocarcinoma.  There was no significant alcohol history.  The patient stated he often travelled to north Thailand where he “ate raw fish” but there was no illness reported in contacts. Physical examination revealed a jaundiced, alert and ambulant patient with no signs of wasting.  Cardiorespiratory examination was normal.  Abdominal examination revealed tenderness, guarding at right hypochondrium with palpable hepatomegaly and positive Murphy’s sign.  There was no abdominal distension or ascites.  He was found to be hepatitis B surface antigen positive with moderate to high viral load given by virus DNA levels of 523 277IU/mL.  He was positive for hepatitis B core antibody and hepatitis B antibody, hepatitis B e e antigen negative, implying chronic infection.  The man had deranged liver function tests including total bilirubin 95?mol/L, ALP 256U/L, ALT 267U/L; AST 289U/L, ?-GT 985U/L but normal albumin (32g/L) and prothrombin time (13.1sec).  Full blood count revealed mild page 1 / 2 JSCR Journal of Surgical Case Reports http://jscr.co.uk 9 9 anaemia, elevated WCC, neutrophils = 8.9×10 /L, eosinophils = 9.1×10 /L and CRP = 223mg/L. Abdominal ultrasound displayed biliary sludge although no gallstones with normal thin-walled gall-bladder.  Abdominal CT-scan with contrast revealed a right liver mass involving segments V to VIII measuring 10.6cm×6cm axially and 10cm craniocaudally with mild caudate lobe hypertrophy suggesting underlying cirrhosis; intra-hepatic bile duct dilation, subcapsular fluid and lymphadenopathy (figure 1). Tumour markers revealed elevated carbohydrate-antigen 19-9 at 807kU/L (normal page 2 / 2 Powered by TCPDF (www.tcpdf.org) http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Journal of Surgical Case Reports Oxford University Press

Liver abscess or neoplasm? A diagnostic and surgical dilemma

Journal of Surgical Case Reports , Volume 2010 (8) – Oct 1, 2010

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References (15)

Publisher
Oxford University Press
Copyright
© Published by Oxford University Press.
eISSN
2042-8812
DOI
10.1093/jscr/2010.8.5
pmid
24946348
Publisher site
See Article on Publisher Site

Abstract

JSCR Journal of Surgical Case Reports http://jscr.co.uk Liver abscess or neoplasm? A diagnostic and surgical dilemma Authors: Hasib Ahmadzai Location: University of New South Wales, Sydney, Australia Citation: Ahmadzai H. Liver abscess or neoplasm? A diagnostic and surgical dilemma. JSCR. 2010. 8:5 ABSTRACT Hepatocellular carcinoma can is often associated with hepatitis B infection.  With localised tumours, liver resection can result in a cure.  This case presents an unusual finding of concurrent hepatitis B and liver fluke infection with hepatocellular carcinoma in a 50 year old man from Thailand.  The discussion illustrates difficulties of arriving at a diagnosis and ensuring appropriate surgical management. INTRODUCTION Hepatocellular carcinoma is known to be strongly associated with hepatitis B infection. This report highlights a rare case of concurrent hepatitis B and liver fluke infection with hepatocellular carcinoma, presenting clinically as a diagnostic and surgical challenge. CASE REPORT A 50 year old male from Thailand presented complaining of right upper quadrant abdominal pain, jaundice, 4kg weight loss over 2 months and hepatomegaly.  His abdominal pain was sharp and intermittent, exacerbated by deep inspiration, although did not radiate and was not associated with eating.  He complained of night sweats and a fever spiking at 40.0°C.  He did not experience nausea, diarrhoea and was able to pass brown stool and clear urine.  He did not have a significant past medical or surgical history, however, his father had died from cholangiocarcinoma.  There was no significant alcohol history.  The patient stated he often travelled to north Thailand where he “ate raw fish” but there was no illness reported in contacts. Physical examination revealed a jaundiced, alert and ambulant patient with no signs of wasting.  Cardiorespiratory examination was normal.  Abdominal examination revealed tenderness, guarding at right hypochondrium with palpable hepatomegaly and positive Murphy’s sign.  There was no abdominal distension or ascites.  He was found to be hepatitis B surface antigen positive with moderate to high viral load given by virus DNA levels of 523 277IU/mL.  He was positive for hepatitis B core antibody and hepatitis B antibody, hepatitis B e e antigen negative, implying chronic infection.  The man had deranged liver function tests including total bilirubin 95?mol/L, ALP 256U/L, ALT 267U/L; AST 289U/L, ?-GT 985U/L but normal albumin (32g/L) and prothrombin time (13.1sec).  Full blood count revealed mild page 1 / 2 JSCR Journal of Surgical Case Reports http://jscr.co.uk 9 9 anaemia, elevated WCC, neutrophils = 8.9×10 /L, eosinophils = 9.1×10 /L and CRP = 223mg/L. Abdominal ultrasound displayed biliary sludge although no gallstones with normal thin-walled gall-bladder.  Abdominal CT-scan with contrast revealed a right liver mass involving segments V to VIII measuring 10.6cm×6cm axially and 10cm craniocaudally with mild caudate lobe hypertrophy suggesting underlying cirrhosis; intra-hepatic bile duct dilation, subcapsular fluid and lymphadenopathy (figure 1). Tumour markers revealed elevated carbohydrate-antigen 19-9 at 807kU/L (normal page 2 / 2 Powered by TCPDF (www.tcpdf.org)

Journal

Journal of Surgical Case ReportsOxford University Press

Published: Oct 1, 2010

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