Hepatic infarction

Case contributed by Thelmo Patricio Zamora Verduga
Diagnosis almost certain

Presentation

Patient who had a liver mass in segment 5, measuring 5 x 4 cm, with diagnostic imaging of hepatocellular carcinoma and who underwent extended segmentectomy. At 48 hours begins to experience dizziness, tremor, hypotension, tachycardia, increased transaminase levels and removing small amount of dark bloody bilious materials through the drain.

Patient Data

Age: 60 years
Gender: Male

Post operative CT abdomen

ct

Postsurgical changes regarding cholecystectomy and extended segmentectomy of segment 5. Peripheral low attenuation area, geographic (triangular) segmental distribution more or less straight margins, limited laterally by the middle and right hepatic veins, with plenty of gas inside the ramifications following portals and bile. These findings are consistent with late liver infarction probably secondary to anterior branch of the right portal vein injury.

Moderate pneumoperitoneum mainly localized perihepatic space and small bubbles dispersed across handles. Striking gastric distension suggests holding stomach accompanied by esophageal dilation. Bilateral pleural effusion, accompanied by right lower lobe collapse. A small amount of free fluid in perihepatic space, Morrison´s space, surrounding the duodenum and Douglas´s space. Bilateral inguinal hernia with fluid in the right content. 

Drainage introduced by the right iliac fossa with perihepatic space distal end.

Overall findings are consistent with late liver infarction of segment 8.

Previous pre-opertative CT

ct

Pre-operative CT demonstrates a a heterogeneous mass in segment 5, measuring 5 x 4 cm, which exhibits typical hepatocellular carcinoma: hypervascular in the arterial phase, with wash on portal and delayed phases.

Central foci are identified in all phases hypoattenuation compatible with intratumoral necrosis and a peripheral ring hypervascular late phase which could correspond to tumor capsule.

Adjacent to this lesion is identified other hypervascular nodular lesion, nonspecific. 9mm identified only in the arterial phase.

Right inguinal hernia containing small bowel loops with no signs of complication.

Left pleural effusion.

Case Discussion

This gentleman was diagnosed with a hepatocellular carcinoma involving segment 5 of the liver, underwent surgical resection which is now complicated with infarction of segment 8 of the liver.

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