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Hepatic adenoma case presentation.dr quiyum
- 1. A case of hepatic adenoma Presented By Dr MD ABDUL QUIYUM Resident phase B,HBS,BSMMU DR. Shahanara Khanam Resident, Phase-A ,Obstetrics and Gynaecology (ICMH)
- 2. Particulars of Patient Name : Mrs. Halima Age : 45 years Sex : Female Religion : Islam Occupation : Housewife Marital Status : Married Address : Faridpur Date of Admission : 19.12.2020 Date of Examination: 20.12.2020
- 3. Particulars of Hospital Bed : FP 1 Unit : Yellow-1 Level : 5th Block : C block Hospital : BSMMU
- 4. Presenting Complaints: soft tissue mass in liver during USG evaluation of amenorrhea for 6 month.
- 5. History of Present Illness According to the statement of the patient, she was reasonably well 6 months ago. Then she developed amenorrhea. Her amenorrhea persists for 6 months associated with menopausal symptoms (hot flush) and during evaluation by local physician, the USG report shows space occupying lesion in the right lobe of liver and FNAC revealed no definitive diagnosis.
- 6. History of Present Illness contd… On query, patient has no history of pain, fever, anorexia and weight loss. she has no history of blood mixed vomiting, passage of black tarry stool during this period. Her bladder and bowel habit is normal. She has no history of cough, chest pain or bone pain, jaundice or any transfusion history.
- 7. History Past history : History of cesarean section for 3 times. Treatment history : Has a history of taking BISOPROLOL + AMLODIPIN for 1 year Allergic history : Not known to allergy to any food or drug. Immunization history : Immunized as per EPI schedule. Personal history : Non smoker, not habituated to betel nut Family history :No history of jaundice or cancer in her family. Socio-economic history :Belongs to lower middle socio-economic status.
- 8. MENSTRUAL HISTORY LMP – 3/4/2020 MP/MC-AMENORRHOEIC AGE OF MENERCHE-13YEARS CONTRACEPTION- OCP taking irregularly for years ,last 10 years. OBSTETRIC HISTORY PERIOD OF MARRIED LIFE:30year PARA: 3+1 AGE OF LAST CHILD:14years
- 9. General Examination Appearance :normal Body built : average Nutritional status : average Anaemia : absent Jaundice : absent Cyanosis : absent Clubbing : absent Koilonychia : absent Leuconychia : absent Oedema : absent Dehydration : absent
- 10. General Examination Contd… Neck Vein : not engorged Lymph Node :not palpable Thyroid Gland :normal Skin Condition and Hair Distribution :normal Pulse :82 b/min Blood Pressure :110/80 mm Hg Temperature :98^F Respiratory Rate :18 breaths/min
- 11. Systemic Examination Gastrointestinal examination: Mouth and oral cavity examination: Lips, gums, teeth, tongue and oral cavity- normal.
- 12. Abdominal Examination Inspection: Shape : normal Umbilicus : Centrally placed, inverted with vertical slit Flanks : not full Visible healthy scar mark was present at lower abdomen of previous of C/S.Surrounding skin condition was normal. No visible engorged vein, peristalsis or visible lump.
- 13. Palpation: Local temperature is normal, Abdomen is soft,non tender, On deep palpation,a spherical mass at RHR ,firm in consistency,mildly tender,moves with respiration continuous with Liver,other movement and fixity cant be assessed. GB couldnot be identified separately. No other organomegaly or lump
- 14. Percussion: Tympanatic. Upper border of liver dullness is in 5th intercostal space on right mid- clavicular line. Shifting dullness: absent Auscultation: Bowel sound present. No hepatic bruits, renal bruits and Splenic rub. Hernial orifices are intact. Groin and external genitalia - normal. Digital Rectal Examination not done. Other Systemic examination Examination of other systems reveals no abnormality.
- 15. Salient Feature Mrs. Halima khatun 45 years old patient presented with space occupying lesion at right lobe of liver during ultrasonic evaluation for amenorrhoea for 6 month.She has no history of pain,fever,weight loss,haematemesis or any symptoms suggestive of metastasis.She had taken OCP irregularly for 20 years and underwent 3 times caesarean section and not positive for HBsAg. On general examination, not anaemic not icteric ,vital parameter within normal limit, liver is palpable. Other systemic examinations reveal no abnormality.
- 16. Provisional Diagnosis Heamangioma involving right lobe of liver Points in favour: Most common benign tomor 1.Sol in liver 2.Long history 3.H/O OCP intake 4.No pain, anorexia, weight loss
- 17. Differential Diagnosis 1.Hepatic adenoma 2. Ca GB 2. HCC 1.Sol in liver 2.H/o taking OCP 3.Long history 1.No history of pain 2.No tenderness 1.Sol in lIver 2.Age of 1.No weight loss 2.No heamatemesis/malaena Spherical mass at RHR Firm in consistency,moved with respiration No pain No weight loss No anorexia
- 18. Approach to manage.. 1. review of USG report 2.further investigation for evaluating SOl
- 19. USG of whole abdomen Liver : Normal in size. Hepatic parenchymal echotexture is bright all over. Hypoechoic mass lesion (8.3cm x 7.6cm) is noted in sub-hepatic region could not separated from liver. GB: partially contracted.wall thickness normal Impression : Hypoechoic mass lesion (8.3cm x 7.6cm) in sub-hepatic region. Hypoechoic mass GB
- 20. USG of Whole Abdomen
- 21. FNAC from mass lesion -----necrotic material
- 22. 1st line investigation CBC LIVER function test Tumor marker Viral marker CE-CT of HBS
- 23. Investigation Profile Complete Blood Count : Hb% -12.2 gm/dl, ESR-15 mm in 1ST hour WBC- 10000/cumm, (N-69% ) LFT S. Bilirubin : 0.7 mg/dl, S. ALP : 268 U/L, S. Albumin : 3.8 gm/dl, PT : 12.0 s & INR : 1.00 S.ALT :20 U/L
- 24. Investigation Profile Contd… Tumour Markers: CA 19-9 : 36 U/ml CEA : 3.42 ng/ml AFP : 2.10 ng/ml Viral marker : HBsAg : Negative AntiHBcAb : Negative Anti HCV : Negative Other GA investigation S. Electrolytes : Na: 136 mmol/l, K: 4.7 mmol/l, Cl: 99 mmol/l Creatinine : 0.86 mg/dl RBS : 4.7 mmol/L Chest X-ray P/A view : Normal ECG : Normal Echocardiography : No RWMA. EF – 66%.
- 25. CE-CT of Whole Abdomen Plain contrast
- 27. CT Scan of Whole Abdomen
- 28. CT SCAN REPORT
- 29. Diagnostic confusion 1. exophytic lesion with central hypodense area (adenoma / FNH) 2.relatively long history ( 6 month) 3.AFP normal. Then we proceed for 2nd line investigation MRI of Liver Sulphar colloid scan
- 32. coronal mrcp
- 33. MRI REPOT
- 34. Liver Scan
- 36. Confirmatory Diagnosis Exophytic Adenoma /HCC arising from segment V of liver :
- 37. Exophytic liver tumor When tumor arising from liver but center of tumor lies outside of liver surface. Exophytic tumor from rt lobe : confusion with origin Then consider : some sign 1. beak sign 2.prominent feeding artery sign 3.phantom organ sign 4.embaded organ sign
- 41. Tc 99 Sn Scan Tc 99 BrIDA scan
- 42. Size 8*11 cm Find : HCC after excision
- 43. Initially as HCC ,after resection showed haemangioma
- 45. Iinitially as HCC later embryonal sarcoma in adult
- 46. Plan of Management CTP –A MELD PS 0 BCLC stage c 8*9 cm Preoperative bowel preparation and =+-consent of stoma Reverse L incision Nonantomic liver resection +- ligation of feeding vessel Post operative surveillance +-chemotherapy
- 47. THANK YOU