Haemochromatosis with hyperdense liver

Case contributed by Dr Jan Frank Gerstenmaier

Presentation

This patient with known haemochromatosis underwent an ultrasound of liver because of weight loss and malaise. AFP within normal limits.

Patient Data

Age: 55
Gender: Male
Ultrasound

Ultrasound of liver

On B-mode ultrasound, the liver parenchyma is of increased echogenicity and coarse echotexture. Centred in segment VIII, there is a well-defined 4.5 cm mass of heterogenous echotexture.

CT

4-phase CT liver

The patient was referred for urgent 4-phase liver because of suspected hepatocellular carcinoma.

MRI

MRI liver

to be sure, to be sure...

Signal changes in the liver are in keeping with iron deposition in haemochromatosis. A second cavernous haemangioma is shown in segment IV. 

Case Discussion

There are several causes for increased hepatic attenuation on CT. In this case, the differentiating feature of primary haemochromatosis is the increased density of the liver only. In secondary haemochromatosis (e.g. frequent transfusions), the spleen would be expected to be hyperdense as well.

CT is not suitable for quantifying iron load in the liver, although this was practised in some institutions until the 1990s (1). However, MR quantification of iron content in the liver, using several gradient recalled echo sequences, is a non-invasive alternative to biopsy. A method of quantification is presented here, including an online calculator (Université de Rennes, France).

Cavernous haemangiomas of the liver are classicaly hypointense relative to liver parenchyma on T1-weighted imaging. In this case, the haemangiomas appear relatively hyperintense because of the diffuse signal drop in the liver parenchyma secondary to iron deposition; there is little, if any iron deposition in the haemangioma.

A hyperdense liver on non-contrast CT is an 'old chestnut' radiology exam case. Watch out for ancillary features that may point to the diagnosis such as pulmonary fibrosis and pacemaker (amiodarone), or increased density in the spleen and pancreas (secondary haemochromatosis).

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Case information

rID: 21568
Case created: 31st Jan 2013
Last edited: 31st Aug 2017
Inclusion in quiz mode: Included

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