Clinical Challenges

Clinical Challenges - January 2018 What's your diagnosis?

Publish date: December 14, 2017

By Mareike Röther, MD, Jean-Francois Dufour, MD, and Beat Schnüriger, MD. Published previously in Gastroenterology (2013;144[3]:510, 659).


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A 62-year-old man with chronic hepatitis C and Child A liver cirrhosis was referred for abdominal computed tomography (CT) after a nodular liver lesion in segment V was found on ultrasonography. His medical history included esophageal varices grade I, reflux esophagitis grade III, and a posttraumatic splenectomy 50 years ago.
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The physical examination was unremarkable and the laboratory values were normal (alpha-fetoprotein, 1.9 mcg/L). Abdominal CT scan revealed a homogenous, smoothly outlined, round lesion measuring 15 × 18 mm located between the gallbladder and the liver (segment V).
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During the arterial phase the lesion seemed to be enhanced (Figure A) and during the venous phase the lesion’s density was similar to the surrounding liver parenchyma (Figure B). To rule out a small hepatocellular carcinoma, diagnostic laparoscopy was performed. The nodule could be visualized at the Calot’s triangle of the gallbladder (Figure C).
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We found unexpected, multiple nodules of different sizes throughout the entire left upper abdominal quadrant. These nodules were located within the greater omentum and the mesentery as well as at the peritoneal surface including the left-sided diaphragm (Figure D).
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Laparoscopic cholecystectomy and resection of the suspicious nodule at the Calot’s triangle was performed. The specimen was sent for histology (Figure E). The postoperative course was uneventful.

What is your diagnosis and treatment?


 

The diagnosis


Answer: Posttraumatic splenosis

Pathologic examination of the specimen revealed a splenosis showing regular red and white pulp (Figure E). Splenosis is the heterotopic autotransplantation of splenic tissue within the abdominal or pelvic cavity and occurs in 16%–67% of patients with a history of splenic trauma or splenic surgery.1 Nevertheless, hepatic splenosis is rare.2 The literature documents only 16 case reports of hepatic splenosis, although the difficulty of diagnosis could have contributed to underreporting. Although usually harmless, splenosis is a rare cause of bowel obstruction or abdominal pain.

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2 Moreover, splenic implants mimicking renal, intestinal, and hepatic masses have been described. 2 Usually, splenosis appears on CT as numerous round to oval structures with absent hilum, and with the same density as the spleen proper. Because CT’s differentiation between tissues can be unreliable,2 selective Tc-99m–labeled heat-denatured autologous red blood cell scintigraphy has been suggested.2 However, the lack of data on the accuracy of Tc-99m-scintigraphy renders its diagnostic efficacy questionable. In our patient with hepatitis C, a diagnostic laparoscopy was indicated to diagnose the posttraumatic splenosis at the infundibulum of the gallbladder. In high-risk patients, detection of a new liver lesion with radiologically uncertain contrast behavior, diagnostic laparoscopy including histologic workup to exclude hepatocellular carcinoma is indicated. Hepatocellular carcinoma usually presents as solitary or multifocal nodules located within the liver parenchyma. Nevertheless, several cases of superficial hepatocellular carcinoma on the surface of the liver have been reported.3 Splenosis may mimic abdominal neoplasia in patients with a history of severe splenic trauma or splenectomy and should be considered during oncologic workup.

References

1. Fleming, C.R., Dickson, E.R., Harrison, E.G. Splenosis: autotransplantation of splenic tissue. Am J Med. 1976;61:414-9.
2. D’Angelica, M., Fong, Y., Blumgart, L.H. Isolated hepatic splenosis: first reported case. HPB Surg. 1998;11:39-42.
3. Ohmoto, K., Mimura, N., Iguchi, Y. et al. Percutaneous microwave coagulation therapy for superficial hepatocellular carcinoma on the surface of the liver. Hepatogastroenterology. 2003;50:1547-51.

ginews@gastro.org

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