This case involves a 29-year-old female teacher presenting with right upper quadrant pain for 3 months and jaundice for 20 days. Investigations revealed elevated liver enzymes and bilirubin. Imaging showed a large hepatic mass and biopsies indicated metastatic adenocarcinoma. The second case is a 61-year-old female with recurrent abdominal pain and vomiting over 4 months. Imaging found an enlarged liver with a large heterogeneous mass. Biopsies were inconclusive but imaging suggested possible gallbladder carcinoma with metastases. Both patients underwent further endoscopic and imaging workup to characterize the liver lesions and evaluate for obstruction.

1. GASTRO – RADIOLOGY MEET
Presenter Dr Naganath K
Moderator Dr Ankur Yadav

3. CASE 1
• 29/F GORAKHPUR
• No comorbidity ,
• Teacher
Presentation :
• Right upper quadrant pain 3months
• Yellowish discolouration of eyes and urine
20days
• Clay coloured stool + Vomiting+ , loss of
appetite , LOW+
• No fever/past surgeries/high risk
behaviour/
• No family h/o similar complaints or
hepatic/biliary disease
Examination
• HT 150 cm Wt 44 kg
• BMI 19.5kg/m2
• Icterus present
• Palpable mass RUQ
epigastrium 10x8cm
• Hepatomegaly+
• Other systems normal

4. Investigations
LFT 15/06/20
23
16/07/23 22/07/2023
T. Bil 2.8 16.4 10.4
D. Bil 0.3 11.5 6.1
T.Protein 7.27 7.1 7.2
Albumin 4.7 4.2 4.1
SGOT 195 200 69
SGPT/GGT 289/230 72 60
ALP 250 343 244
INR 1.1 1.0 1.1
Ca 19.9 >10000u/ml
CEA 939 ng/ml
Ca 125 30u/ml
HBsAg/HIV/AntiHC
V
Neg
AFP 2.4
CBC 16/7/23 22/07/23
HGB 8.3 8.2
TLC 39.2 31.2
PLT 195 264
RFT Normal

5. Clinical possibilities
Extrahepatic Biliary Obstruction partial GOO
• Ca GB
• Cholangio Ca
• Hepatic Mets
• Giant Hepatic hemangioma

6. Liver SOL Biopsy HPE-12/7/23
• Tumor diposed predominantly in cords and vague glands. The
individual tumor cells show moderately anisomorphic irregular nuclei,
condensed chromatin, inconspicuous nucleoli and moderate amount
of eosinophilic cytoplasm. Adjoining stroma shows desmoplasia.
CONCLUSION: METASTATIC ADENOCARCINOMA.

7. Case 2
• 61 y/F
• No comorbidity
• Recurrent pain abdomen - 4months
• Recurrent vomiting –months
• Obstipation +
• Requiring hospitalisation.
• Last episode 1 month back
• Weight loss+
• No melena/hematemesis/fever
• Examination : normal
• Clinical Possibilitis
Recurrent Subacute int
obstruction
1) ITB
2) Crohns disease
3) Intestinal malignancy

8. Investigations
CBC 13.3/8.0/374
LFT Protein 6.1 /Alb 2.9
RFT Normal
Fecal Cal 219.5mg/Kg
USG abd : Mild Hepatomegaly

13. USG ABDOMEN
• Liver-is enlarged in size (16.2 cm) with e/o large heteroechoic
mass lesion seen, measuring approx. 12.8x9.8cm involving liver
parenchyma. The lesion shows vascularity on colour doppler.
Portal vein is poorly visualized.
• Gall bladder- fully distended. No calculus in lumen Wall thickness
is normal.
• CBD- normal.
• Pancreas in normal in thickness. Clearly defined margins are seen.
Pancreatic duct is not dilated.
• Spleen is normal in size (9.6 cm). No focal lesion is seen.

14. CRNO: 2023482396 29/F
• CHIEF COMPLAINS: Pain right upper abdomen and epigastrium- 3
months.
• Jaundice- 15 days

15. IgG 1620
ESR 108
FLUID GLUCOSE 116
BUN 41.40
S. Creatinine 2.26
S.Chloride 117
S. Phosphorous 4.78

16. HISTORY OF PRESENT ILLNESS
• Pain in RHC which was insidious in onset, dull aching in nature, mild
to moderate intensity, radiating to back, no aggravating factors,
releaved after taking oral analgesics.
• It was associated with nausea and vomitting occasional every 4-5 days
gastric content 50- 100 ml, h/o post prandial fullness.
• H/o jaundice since 15 days insidious onset ,progressively increasing in
intensity, associated with high colored urine and clay colored stool.

17. NEGATIVE HISTORY
• No H/O fever
• No H/o hematemesis , malena
• No h/o altered bowel habits
• No H/s/o fat soluble vitamin deficiency
• No h/s/o CLD or hypersplenism

18. PAST HISTORY
• No MRF, no surgery, NO H/O ATT intake

19. FAMILY HISTORY
• No h/o similar disease in family, no h/o any malignancy in the family.

20. PERSONAL HISTORY
• Vegetarian, appetite reduced, sleep disturbed , bowel and bladder
habits regular.

21. EXAMINATION
• Patient is conscious / oriented
• ECOG - 0,METS > 4, KPS 90
• HT 150 cm Wt 44 kg. BMI 19.55 BHT 35sec
• Icterus present
• No pallor/ cyanosis/ pedal odema
• Afebrile.
• PR - 80/min.
• BP - 120/80mmHg.

22. • Chest : BLAE present
• PA : Umbilicus central inverted, no scar/ sinus.
Tender RHC on deep palpation,10 x8 cm lump palpable in
epigastrium, moving with respiration, dull on percussion, palpable
hepatomegaly present.

23. USG ABDOMEN (19/5 2023)
• Liver-Increased in size, measuring 16.0 cm & coarse echogenicity.
Large well defined heterogeneous lesion measuring 11.0 x 80 cm seen
in right lobe s/o hepatic mass.
• GB- Contracted, e/o multiple small calcali seen in GB largest
measuring 7.0 mm. Wall is normal.
• CBD- Normal in course and calibre.
• SPLEEN- normal.
• PANCREAS- Normal.

24. USG ABDOMEN (21/5 /2023)
• Liver-is enlarged in size (16.2 cm) with e/o large hetroechoic mass lesion is
seen, measuring approx. 12.8x9.8cm involving liver parenchyma. The lesion
shows vascularity on colour doppler. Portal vein is poorly visualized.
• Gall bladder- fully distended. No calculus in lumen Wall thickness in
normal.
• CBD- normal.
• Pancreas in normal in thickness. Clearly defined margins are seen.
Pancreatic duct is not dilated.
• Spleen is normal in size (9.6 cm). No focal lesion is seen. Diaphragmatic
movements are within normal limits on both sides.

25. CECT ABDOMEN ( 20/05/23)
• Liver is enlarged in size (16.0 cm) and shows a large heterogeneous
lesion with predominant peripheral enhancement on portovenous
phase. Lesion in predominantly located in segment 4. and 8. It is
causing mass effect is form of posterior displacement and splaying of
main portal branches.
• A similar smaller lesion of size-32 x 27 mm is noted in porto-caval
region.
• Gall bladder- is contracted and shows subtle hyperdensity-
?Cholelithiasis. CBD is not dilated
• Pancreas - normal

26. CECT ABDOMEN ( 21 /5/23)
• Liver is enlarged in size with e/o large peripheral arterial enhancing
mass, measuring approx 14x10x8.5cm predominantly involving right
lobe of liver. The lesion show increased enhancement during
photovenous and delayed phase with suggestion of centripetal filling
however no obvious discontinuous peripheral enhancement can be
made out.
• Mass effect over portal with compression of effacement of right
branch of the portal vein. minimal fluid is seen in pelvic cavity.
• Small similar focal lesion are also noted in portocaval region
extending into caudate lobe giant hemangioma /?? FNH / ??
adenoma

27. TPCT Abdomen-7/7/23
• Relatively well defined large (- 18.8 x 14.9 x 16.4 cm) with irregular
heterogenously enhancing lesion is seen in both lobes of liver, causing mass
effect over hila with no separate visualization of the gall bladder. Mass is
involving CHD and causing upstream bilobar IHBRD. Primary confluence is
just formed. Mass effect is seen in the form of displacement of adjacent
bowel loops and abdominal viscera, with maintained fat planes.
• BD is not visualised and is compressed by necrotic enlarged nodes.
Multiple variable sized arterially enhancing lesion is seen in the body and
tail region of the pancreas ? metastasis ??Less likely neuro endocrine
tumour (~12X14mm). MPD is diffusely dilated ~ 3.4 mm .No obvious
peripancreatic fat stranding/collections noted. Multiple heterogenously
enhancing lymph nodes are seen in pre and paraaortic, aortocaval, &
paracaval and periportal region, largest SAD ~ 13 mm. Mild ascites is seen.

28. • IMPRESSION:
• Large well defined heterogeneously enhancing liver lesion with no
separate visualization of gall bladder....? Primary gall bladder
carcinoma. Multiple pancreatic and nodal metastasis Well defined
cystic lesion in right adnexa showing dependent pre- contrast
hyperdensity (s/o hemorrhagic content) --- ? Hemorrhagic cyst (adv:
USG correlation).

29. UGIE-10/7/23
• Impression: Duodenal ulcer forrest class III with partial GOO
Erythematous mucosa seen in antrum
Multiple D1 and antral biopsies taken

30. ERCP-20/7/23
• SVE-Papilla normal. Selective CBD cannulation done. Cholangiogram
done - showed left IHBRD > right. The wire was manipulated to seg III
duct - dilated. Cholangiogram done for confirmation. 10F x 10cm
plastic stent placed in LHD-seg III duct. Drainage of contrast seen.

31. HPE REPORT-11/7/23
• DUODENAL BIOPSY: NO E/O villous atrophy or pasarite; gastric antral
biopsy: Helicobactor pylori associated active gastritis.