RUQ Mass

Cepeda, Patricia Anne Cerdeno, Marrianne Cervantes, Krystal

CASE
General Data: 57 year old Filipino male Chief complaint: Abdominal mass

HPI
2 months PTA Progressively enlarging mass at RUQ anorexia and weight loss of 15 lbs. No other accompanying symptoms

ADMISSION

 Personal History:
Alcoholic beverage drinker - 10 years Smoker - 8 pack years

Past Medical History

2 years ago: closed tube thoracostomy for stab wound to the chest transfused with 2 units of homologous blood

Physical examination
BP- 140/90; PR 86/min; RR 18/min; Temp 36.8C HEENT: pinkish palpebral conjunctivae; sclerae not icteric; no palpable cervical lymph nodes Chest wall: 2 scars (stab wound & CTT scars) at right chest along mid-axillary line; no spider angiomata Heart and Lungs: essentially unremarkable Abdomen: asymmetrical with bulging RUQ; palpable mass at RUQ, not tender, nodular, moves with respiration, no bruit; fluid wave

Extremities: no deformities
Rectal exam: unremarkable

Ultrasound of the Liver

Salient Features
Subjective
57 year old Filipino male Alcoholic beverage drinker - 10 years 8 pack years smoking history Progressively enlarging mass at RUQ anorexia and weight loss of 15 lbs Blood transfusion

Objective
BP- 140/90 Abdomen is asymmetrical with bulging RUQ; palpable mass at RUQ, nontender, nodular, moves with respiration no spider angiomata, no fluid wave
Extremities: no deformities

Rectal exam: unremarkable

FROM THE HISTORY AND PE WHAT ARE YOUR PRIMARY CONSIDERATIONS?

Abdominal Mass at RUQ Hepatic Extra-hepatic

Bile duct

Gall bladder

Abdominal Mass at RUQ Hepatic Extra-hepatic Malignant

Hepatocellular carcinoma
Metastasis from other organs

Benign Mass
Hemangioma Adenoma Focal Nodular Hyperplasia Alcoholic liver disease/Cirrhosis Infection

Hemangioma
hemangiomata Most common solid benign masses that occur in the liver Represent congenital vascular lesions that contain fibrous tissue and small blood vessels which eventually grow Most common symptom is pain which occurs with lesions larger than 5-6cm F>M

Adenoma
Benign solid neoplasms of the liver RF: prior or current use of estrogens (OCP) F>M, young Typically solitary Usually it presents with palpable mass and abdominal pain at RUQ area 25% of patients presents with spontaneous rupture with hemorrhage -> pain Risk of malignant transformation to a welldifferentiated HCC

Focal Nodular Hyperplasia

Solid, benign lesion of the liver F>M; weak association with OCPs, common in women of childbearing age Asymptomatic Discovered incidentally Spontaneous rupture is rare No significant risk of malignant transformation May present as single or multiple lesions with nodular appearance

Alcoholic liver disease/Cirrhosis

History of chronic and excessive alcohol intake Threshold for developing severe alcoholic liver disease in men is intake of >60-80g of alcohol for 10 years (1 bottle of beer = 12 g of alcohol) Nonspecific sx: Vague RUQ pain, fever, nausea, anorexia, malaise Liver and spleen may be enlarged and liver edge is firm and nodular Other frequent findings: scleral icterus, palmar erythema, spider angioma, parotid gland enlargement, digital clubbing, muscle wasting, edema, ascites

Infection/Hepatitis Virus
Hepatitis B and C Chronic liver disease, cirrhosis and hepatocellular carcinoma Non-specific prodrome
anorexia, nausea and vomiting, fatigue, malaise, arthralgias, myalgias, headache, photophobia, pharyngitis, cough, and coryza may precede the onset of jaundice by 12 weeks

Clinical jaundice
liver becomes enlarged and tender and may be associated with right upper quadrant pain and discomfort

Recovery phase
constitutional symptoms disappear, but usually some liver enlargement and abnormalities in liver biochemical tests are still evident

Hepatocellular carcinoma
One of the most common malignancies worlwide Male to female ratio of 4:1 Mean age (years) = 56 +/- 13 Major risk factors: viral hepatitis (B or C), alcoholic cirrhosis, hemochromatosis, and nonalcoholic steatohepatitis, aflatoxin B or other mycotoxins Symptoms: abdominal pain, weight loss, weakness, abdominal fullness and swelling, jaundice and nausea Hepatomegaly is the most common physical sign Abdominal swelling may occur as a consequence of ascites due to the underlying chronic liver disease or may be due to a rapidly expanding tumor Others: abdominal bruit, ascites, splenomegaly, muscle wasting and weight loss

Tumors metastatic to the liver

Predominantly from colon, pancreas, breast Poor prognosis

Gallbladder Cancer
Usually related with gall bladder stones Presentation is typically that of chronic cholecystitis, chronic right upper quadrant pain and weight loss

Cholangiocarcinoma
Mucin-producing adenocarcinomas (different from HCC) that arise from the bile ducts Rare Painless jaundice, often with pruritus or weight loss, and acholic stools Predisposing factors
Hepatobiliary parasitic infection (Opisthorchis viverrini and Clonorchis sinensis) Congenital anomalies congenital biliary atresia Sclerosing cholangitis

Most likely diagnosis

Hepatocellular carcinoma, secondary to chronic liver disease