Hepatic loss in a young patient: a very ‘cold case’

Dr. De Francesco. A 28-year-old male farmer, complaining of mild, recurrent right upper quadrant and chest pain was referred to gastroenterology. The patient had received sporadic and unsuccessful NSAID-based therapy during the prior 2 years. Bowel movements were regular and no fever was present. He smoked ten cigarettes daily. Physical examination was unrewarding, but abdomen palpation revealed exacerbation of tenderness in the liver area with modest hepatomegaly. An abdominal ultrasonography was performed showing a round mass, 8 cm in diameter, localized in the right hepatic lobe, with a heterogeneous ultrasound signal in the central area. Laboratory tests found elevated levels of alanine aminotransferase (91.5 normal value), alkaline phosphatase and c-glutamyltranspeptidase (both 9 1.3 normal value) and increased values of erythrosedimentation rate (48 mm/h), C-reactive protein (95.5 normal value), cholesterol level (91.2 normal value) and triglycerides level (92 normal value); all other biochemical tests, including a-fetoprotein, were in the normal range. Computed tomography (CT scan) confirmed the presence of a round mass (11 9 10 cm) in the right hepatic lobe, compressing the right hepatic vein. The lesion appeared heterogeneous and hypodense, with a peripheral enhancement in the arterial phase and low enhancement in the portal and delayed phase. A pseudo-capsule was evident with a small interruption in the proximity of a satellite nodule of 1 cm (Fig. 1).