British Journal of Radiology (2007) 80, 293-295
© 2007 British Institute of Radiology
doi: 10.1259/bjr/22132984
Solitary liver lesion in a patient with blunt abdominal trauma
M Weinrich, MD
1
R Seidel, MD
2 and
G A Pistorius, MD, PhD
1
1 Department of Abdominal, Visceral, Vascular and Pediatric Surgery, 2 Department of Diagnostic and Interventional Radiology, University Hospital of the Saarland, D-66421 Homburg/Saar, Germany
Correspondence: Dr Malte Weinrich, Department of Abdominal, Visceral, Vascular and Paediatric Surgery, University Hospital of the Saarland, Kirrberger Strasse, 66421, Homburg/Saar, Germany. E-mail: chmwei{at}uniklinik-saarland.de
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Introduction
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A 61-year-old male patient received a blunt chest and abdominal trauma when he was pressed against a wall by a bull. After admission to another clinic conventional radiographs showed bilateral rib fractures (6 to 11 on the right and 4 to 9 on the left side) with a haematopneumothorax on the right side and a fractured left scapula. Unenhanced CT scan confirmed several rib fractures on both sides with one fragment protruding into the right abdominal cavity (Figure 1a
). Furthermore, it showed a hypoattenuating area, 6 cm in maximum diameter, within liver segments 7 and 8. After administration of contrast media the lesion demonstrated an inhomogeneous enhancement pattern in the equilibrium phase (Figure 1b). No leakage of contrast media was seen. The lesion was considered to represent a liver contusion. Therefore the patient was managed without surgery except for the placement of a chest tube on the right, and he made a satisfactory recovery. Do you agree with the interpretation of the radiological findings? What would be your diagnosis?
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Figure 1. (a) Unenhanced CT scan showing a hypoattenuating area of irregular shape within liver segments 7 and 8 (cross). (b) After administration of contrast media a peripheral and partially septal enhancement of the lesion is detectable (cross).
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9 years after the trauma the patient presented with complaints of non-specific abdominal pain in the upper right quadrant. Besides growth of the focal hepatic abnormality (Figure 2) present CT scan showed unchanged imaging characteristics of the hypoattenuating liver lesion with septal and a marginal perifocal enhancement of the surrounding liver tissue following administration of iodinated contrast media.
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Figure 2. Contrast-enhanced CT scan 9 years after the trauma demonstrates a progressive multiloculated hypoattenuating lesion with unchanged septal enhancement.
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Additional MR scan revealed a multiloculated lesion, 12 cm in maximum diameter, extending into the hilum of the liver with hyperintense signal intensity on T2 weighted half-Fourier acquisition single shot turbo spin echo (HASTE) and turbo spin echo (TSE) images and hypointense signal intensity on T1 weighted gradient echo (GRE) images with and without fat suppression indicating a cystic character of the lesion (Figure 3). The cystic components, measuring up to 1.5 cm in diameter, were separated by thin septal structures which were enhanced after administration of contrast media (Gd-BOPTA; Bracco Co., Milan, Italy) (Figure 3c). There was no uptake of contrast media in the hepatobiliary phase. The lesion caused the liver capsule to bulge into the peritoneal cavity, but no peritoneal thickening or intraperitoneal fluid collection as an indirect sign for a peritoneal spread was seen. The imaging findings led to the diagnosis of a parasitic cyst and decision for an explorative laparotomy was made.
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Figure 3. MR scan in(a) axial T2 weighted turbo spin echo (TSE) sequence and in (b) coronal T2 weighted HASTE sequence reveals a multicystic liver lesion. The cystic components with hyperintense signal intensity are separated by thin septal structures. (c) After administration of contrast media (Gd-BOPTA) a septal enhancement and a marginal peripheral enhancement of the surrounding liver tissue is observed [arrow, axial T1 weighted gradient echo (GRE) sequence].
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Macroscopically the lesion had the appearance of a hydatid cyst with widespread daughter cysts throughout the peritoneal cavity. This was confirmed histologically during surgery. A complete resection of the lesion would only have been possible by means of a right hemihepatectomy which was not performed because of the peritoneal spread and a macroscopic fatty degeneration of the liver. Therefore the lesion was removed by performing an atypical (non-anatomical) liver resection and a peritoneal debulking was performed. An antiparasitic treatment with albendazole was started immediately after surgery, and the post-operative course was uneventful.
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Discussion
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The initial CT scan showed an irregular shaped intrahepatic lesion without calcifications. After administration of contrast media the lesion was hypoperfused with a slight peripheral rim and septal enhancement. These findings and the lack of subcapsular or perihepatic haematoma make the diagnosis of liver trauma unlikely. The right-sided haematopneumothorax with soft tissue emphysema, multiple rib fractures and the rib fragment penetrating the peritoneal cavity indicate a severe blunt trauma which possibly led the radiologist to his misinterpretation of the imaging findings. Except for the increase in size of the hepatic lesion the recent CT scan did not provide additional information. MR imaging supported the suspected diagnosis demonstrating a multiloculated liver lesion with small cystic components.
The differential diagnosis of polycystic liver lesions comprises a variety of benign and malignant pathologies with an overlap of diagnostic criteria at cross-sectional imaging. Polycystic liver disease has similar morphological imaging characteristics except for absent wall enhancement during contrast-enhanced imaging and usually less localized distribution of the cysts [1, 2]. Biliary hamartoma is a rare but possible differential diagnosis. Its cysts are also usually no larger than 1.5 cm in diameter but do not demonstrate rim enhancement or calcifications [3]. Caroli's disease is characterized by small cystic lesions with the central dot sign representing a contrast-enhanced portal vein radical [4]. Intrahepatic abscess formations or cystic degenerations of liver metastases usually demonstrate enhancing wall structures of more irregular and ill-defined shape [5].
The misinterpretation of the liver lesion led to a 9 year delay in correct diagnosis of a hydatid cyst. Radical surgical resection is still the first line of treatment in echinococcosis with good long-term outcome and low morbidity [6, 7]. An earlier diagnosis in the present case might have prevented peritoneal spread of the parasites and would have made curative treatment more probable.
Received for publication August 19, 2005.
Revision received November 25, 2005.
Accepted for publication December 5, 2005.
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References
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Introduction
Discussion
