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Multiple infarcted regenerative nodules in liver cirrhosis after decompensation of cirrhosis: a case series

Scholtze D, Reineke T, Müllhaupt B, Gubler C - J Med Case Rep (2010)

Bottom Line: It is important to know the wide spectrum of image appearances of these lesions.Hypotension can lead to a reduction of portal and arterial liver flow.Since variceal bleeding or septic shock can induce hypotension - as observed in our patients - we conclude that this leads to infarction of such nodules.

Affiliation: Department of Internal Medicine, University Hospital Zurich, Raemistrasse 100, 8051 Zurich, Switzerland. dieter.scholtze@waid.zuerich.ch.

ABSTRACT

Introduction: Liver cirrhosis is a common disease with many known complications. Cirrhosis represents a clinical spectrum, ranging from asymptomatic liver disease to hepatic decompensation. Manifestations of hepatic decompensation include variceal bleeding, ascites, hepatic encephalopathy, hepatorenal syndrome, hepatopulmonary syndrome, portopulmonary hypertension and hepatocellular carcinoma. There are reports about infarcted regenerative nodules in cirrhotic livers after gastrointestinal hemorrhage.

Case presentation: We report three Caucasian patients (one female and two male patients; ages: 52, 54 and 60 years) with decompensated liver cirrhosis, who showed newly infarcted regenerative nodules at necropsy. Two of them suffered from gastric variceal bleeding. Histopathology showed extensive infarction in all three cases.Hemorrhage and inflammatory changes were also observed around the infarcted regenerative nodules.

Conclusion: These patients showed focal liver lesions, to be considered in the differential diagnosis of cirrhotic livers. Infarcted regenerative nodules may be underdiagnosed in patients with decompensation of cirrhosis. In order to differentiate these lesions from malignant tumors, serial imaging seems to be helpful. However, the main differential diagnosis should be an abscess. It is important to know the wide spectrum of image appearances of these lesions. Hypotension can lead to a reduction of portal and arterial liver flow. Since variceal bleeding or septic shock can induce hypotension - as observed in our patients - we conclude that this leads to infarction of such nodules.

Hypodense lesion (27 × 23 mm) in ultrasound.
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Figure 1: Hypodense lesion (27 × 23 mm) in ultrasound.

Mentions: One of the patients, a 54-year-old Caucasian male with viral hepatitis-induced liver cirrhosis, came to the emergency room due to acute respiratory insufficiency and hepatic encephalopathy grade IV. Chest x-ray revealed severe pneumonia. Except for the signs of liver cirrhosis the first abdominal CT scan did not show any pathological findings. However, 10 days later an abdominal ultrasound showed two new intrahepatic lesions (Figure 1). In spite of medical therapy the patient's liver function worsened with severe encephalopathy leading to death after one month. The autopsy revealed multiple fresh necrotic lesions in the liver. On histopathological examination two lesions (1.5 × 2.7 cm and 1.0 × 2.2 cm) were identified as infarcted regenerative nodules showing coagulative necrosis (Figure 2). The other lesions were described as necrotic lesions by chronic hepatitis C.

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Multiple infarcted regenerative nodules in liver cirrhosis after decompensation of cirrhosis: a case series

Scholtze D, Reineke T, Müllhaupt B, Gubler C - J Med Case Rep (2010)

Hypodense lesion (27 × 23 mm) in ultrasound.
© Copyright Policy - open-access
Figure 1: Hypodense lesion (27 × 23 mm) in ultrasound.
Mentions: One of the patients, a 54-year-old Caucasian male with viral hepatitis-induced liver cirrhosis, came to the emergency room due to acute respiratory insufficiency and hepatic encephalopathy grade IV. Chest x-ray revealed severe pneumonia. Except for the signs of liver cirrhosis the first abdominal CT scan did not show any pathological findings. However, 10 days later an abdominal ultrasound showed two new intrahepatic lesions (Figure 1). In spite of medical therapy the patient's liver function worsened with severe encephalopathy leading to death after one month. The autopsy revealed multiple fresh necrotic lesions in the liver. On histopathological examination two lesions (1.5 × 2.7 cm and 1.0 × 2.2 cm) were identified as infarcted regenerative nodules showing coagulative necrosis (Figure 2). The other lesions were described as necrotic lesions by chronic hepatitis C.

Bottom Line: It is important to know the wide spectrum of image appearances of these lesions.Hypotension can lead to a reduction of portal and arterial liver flow.Since variceal bleeding or septic shock can induce hypotension - as observed in our patients - we conclude that this leads to infarction of such nodules.

Affiliation: Department of Internal Medicine, University Hospital Zurich, Raemistrasse 100, 8051 Zurich, Switzerland. dieter.scholtze@waid.zuerich.ch.

ABSTRACT

Introduction: Liver cirrhosis is a common disease with many known complications. Cirrhosis represents a clinical spectrum, ranging from asymptomatic liver disease to hepatic decompensation. Manifestations of hepatic decompensation include variceal bleeding, ascites, hepatic encephalopathy, hepatorenal syndrome, hepatopulmonary syndrome, portopulmonary hypertension and hepatocellular carcinoma. There are reports about infarcted regenerative nodules in cirrhotic livers after gastrointestinal hemorrhage.

Case presentation: We report three Caucasian patients (one female and two male patients; ages: 52, 54 and 60 years) with decompensated liver cirrhosis, who showed newly infarcted regenerative nodules at necropsy. Two of them suffered from gastric variceal bleeding. Histopathology showed extensive infarction in all three cases.Hemorrhage and inflammatory changes were also observed around the infarcted regenerative nodules.

Conclusion: These patients showed focal liver lesions, to be considered in the differential diagnosis of cirrhotic livers. Infarcted regenerative nodules may be underdiagnosed in patients with decompensation of cirrhosis. In order to differentiate these lesions from malignant tumors, serial imaging seems to be helpful. However, the main differential diagnosis should be an abscess. It is important to know the wide spectrum of image appearances of these lesions. Hypotension can lead to a reduction of portal and arterial liver flow. Since variceal bleeding or septic shock can induce hypotension - as observed in our patients - we conclude that this leads to infarction of such nodules.

View Similar Images In: Results  - Collection
View Article: MedlinePlus - PubMed Central - HTML -  PubMed
Show All Figures - Show MeSH
getmorefigures.php?pmc=3003675&rFormat=json&query=null&req=5