Presentation
Known right ventricular dysfunction on treatment, reports a history of epigastric pain radiating to the right upper quadrant. On examination, laparotomy scar due to hernioplasty done last year. tender epigastric region plus right upper quadrant, hepatomegaly 6 cm below the costal margin. Mild tenderness at the RIF/ no obvious mass at RIF.
Patient Data
Dilated intra-hepatic veins (right, middle and left hepatic veins) resembling a bunny (aka Mumoli or rabbit sign). The right medial half hepatic vein diameter of 1.44 cm and the proximal inferior vena cava diameter of 2.84 cm are noted. The liver surface parenchyma is mildly diffusely coarse in reflectivity. The main portal vein diameter of 1.01 cm noted is normal however, spectral Doppler analysis of the main portal vein exhibit pulsatile (hepatofugal) flow pattern.
No ascites or pleural effusion. Small simple, reducible supra-umbilical hernia (recurrent post herniorrhaphy) containing omentocele is noted.
Transthoracic (parasternal long and short axes views plus apical 4-chamber) cardiac assessment demonstrates borderline cardiomegaly with dilated atrial chambers. The mitral and aortic valves are calcified, thickened, hyperechoic and mildly stenosed with subtle akinesia. The Mercedes Benz sign of the aortic valve is lost. Globally reduced myocardial wall motions accompanied by moderately depressed left ventricular ejection fraction are appreciated. No pericardial effusion.
Case Discussion
Echocardiography still remains the most commonly used tool for the diagnosis of congestive cardiac failure (CCF) plus other cardiomyopathies. However, critical features pointing towards CCF changes may be picked during routine abdominal ultrasound scans (like in this case) in patients that are/are not clinically suspected with cardiac failure.
In this presentation, the hepatic veins and the IVC are grossly engorged prompting an operator to peep through the heart which now shows multifaceted cardiomyopathy consistent with congestive heart disease. Hepatofugal flow, plus coarse hepatic parenchyma reflectivity seen, suggest chronic parenchymal liver disease, likely cirrhosis.
Supero-medial right renal cortex is focally thinned out suggesting segmental chronic parenchymal renal disease ipsilaterally. Noteworthy is that no sonographic evidence of appendicitis or masses during the abdominal ultrasound examination.
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