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Thread: What Is The Differential Diagnosis of Hepatomegaly?

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    What Is The Differential Diagnosis of Hepatomegaly?

    Patient Presentation

    A 9-year-old male came to clinic with fever and stomachache. His rapid strep was positive and he was treated with penicillin. Three weeks later he complained of abdominal pain again, accompanied by a low-grade fever, some nausea, early satiety and mild fatigue.

    He had no sore throat, diarrhea, changes in bowel or urinary patterns, upper respiratory symptoms, or rashes. Some of his friends had colds, and he had no pet exposure or travel history.

    The past medical history showed a healthy male. The review of systems revealed no night sweats, weight loss, pruritus, jaundice, bleeding, bruising, or other pain.

    The pertinent physical exam showed a slightly tired male in no distress. His temperature was 38.2 Celsius, he had a 1 pound weight loss from the previous visit, but the rest of the vital signs were normal. HEENT showed no icterus and some anterior cervical nodes that were <0.5 cm. He had no other lymphadenopathy.

    His abdominal examination showed fullness of the right side of the abdomen and a liver edge that was 2-3 cm above the umbilicus and crossing the midline. He had no splenomegaly, other palpable masses or ascites. He had no skin changes including prominent vessels.

    The radiologic evaluation of right upper quadrant ultrasound found a large heterogeneous mass in the right lobe of the liver. The patient was transferred to a regional children's hospital for further evaluation where a CT scan confirmed the diagnosis.

    He was taken to the operating room where a resection of the right lobe of the liver and mass was completed. Anatomic pathology reported a diagnosis of embryonal cell sarcoma with tumor free surgical margins and negative abdominal lymph node biopsies.

    The laboratory evaluation included liver function tests, hepatitis panel, alpha-fetoprotein levels, human chorionic gonadotropin levels, carcinoembryonic antigen, and routine cancer markers. All were negative. The patient's clinical course post-operatively was uneventful and he was begun on chemotherapy.
    Figure 67 - Axial image from an ultrasound exam of the liver shows a large inhomogenous mass in the right lobe of the liver. The mass is primarily hyperechoic in appearance, with multiple hypoechoic regions within it.
    Figure 68 - A coronal two dimensional reconstruction delayed phase image of the liver from a computed tomography exam of the abdomen performed with oral and intravenous contrast. A large lesion, measuring 12 cm in diameter, is seen in the right lobe of the liver. There is peripheral vascular enhancement of the mass, which has a primarily necrotic center. Differential diagnosis included hepatoblastoma, hepatocellular carcinoma, and embryonal sarcoma.

    Questions for Further Discussion
    1. What other organs can cause factitious enlargement of the liver?
    2. What laboratory testing should be considered for initial evaluation of hepatomegaly?
    3. What are the indications for liver transplantation?


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