A4) RUQ abdominal pain, weight loss, and fatigue

Review the Learning Outcomes, Hx, PE and Labs, and begin the module with your Provisional Diagnosis. Keep hitting "Next" to move through the module.

Learning Outcomes

  1. Articulate your relationship with the consulting diagnostic radiologists in the evaluation of a patient with abdominal pain.
  2. Review the DDx considerations in a patient with abdominal pain.
  3. Identify the spectrum of imaging findings in appropriate modalities for evaluating a patient with abdominal pain.

History

Physical Exam

Labs

Provisional Diagnosis

Select the Dx you believe is most appropriate
The patient is most likely presenting with all of the above. The patient likely has hepatomegaly considering the liver edge palpable more than 2 cm below the costal margin. Furthermore, the patient likely has cirrhosis considering that it is firm and irregular on exam and has alcohol use disorder, chronic hepatitis B infection, chronic (or acute) hepatitis C infection, and elevated liver function tests. This patient with cirrhosis with Hepatitis B and C co-infection, constitutional symptoms, anemia, and elevated AFP, may have hepatocellular carcinoma (HCC).
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Potential Acuity

What is your assessment of the likely acuity for this patient?

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The patient requires routine, but expedited workup.

First Imaging Study

What is the first imaging study you will order?

A three-phase abdominal CT is likely an available option in a rural hospital. The multiphase allows for an evaluation of the enhancement pattern. Appropriate options also include an abdominal ultrasound and MRI of the abdomen with and without contrast or ultrasound. The CT is shown for the purpose of this case.
View ACR Appropriateness Criteria
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Pertinent Imaging Observations

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View Report

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Second Imaging Study

What is the next imaging study you will order?

CT is highly sensitive in HCC that is >2cm, therefore further imaging is not needed.
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What is your Diagnosis now that you have seen the imaging results?

The HCC is in liver segment VIII as it is in the posterior right dome of the liver.

Current Acuity

Initially, you selected and we suggested acuity.

Has your concern for this patient changed?

Routine, but expedited workup is needed.

Assessment and Plan

Please provide your assessment and plan for this patient

This is a 62-year-old male with alcohol use disorder and Hepatitis B and C co-infection presenting with imaging and lab findings concerning for HCC. Medical, surgical, and interventional oncology should be consulted for further evaluation and management. Gastroenterology should be consulted for management of the hepatitis B and C infections. Social work should be referred for substance abuse counseling.

Lessons Learned:
- HCC is the most common primary liver malignancy.
- Risk factors for HCC include cirrhosis, alcohol use, viral hepatitis infections, hereditary and hepatotoxin exposure.
- Abdominal MRI with and without contrast or ultrasound are appropriate initial screening modalities in high risk patients.
- CT is highly sensitive for HCC lesions >2cm. If a multiphase CT is performed, it will demonstrate avid enhancement on the arterial phase and rapid washout on subsequent phases. This occurs because the HCC is primarily supplied by the hepatic artery. There is also often rim enhancement, appearing as a pseudocapsule, on contrasted images. Invasion of nearby vascular structures may also occur.

Socioeconomic Factors:
- HCC is the fifth most common cancer worldwide.
- Exposure to pesticides, aflatoxins, and betel nut chewing has been correlated to an elevated risk of developing HCC.

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