2018-01-03 17:07:44 UTC

Image Challenge: Abdominal Pain, Deranged Liver Function and Fevers

Jan. 3, 2018

What caused fevers, right upper quadrant pain and an elevated C-reactive protein in a 41-year-old patient?

Gastroenterology Clinical Image Challenge: A 41-year-old man presented with sudden-onset upper abdominal pain and fevers. His only past medical history was antiphospholipid syndrome, diagnosed after two deep vein thromboses, and discoid lupus. He had been treated with warfarin for >10 years, but took no other medications.

On examination, he had a soft but tender abdomen in the right upper quadrant. Admission blood tests revealed a bilirubin of 29 μmol/L, alanine transaminase of 36 U/L, alkaline phosphatase of 225 U/L, creatinine of 61 μmol/L, C-reactive protein of 314 mg/L, white cell count of 8 × 109/L and an International Normalized Ratio of six. He was transferred to the hepatology team with a provisional diagnosis of liver abscesses. Computed tomography of the abdomen and magnetic resonance imaging of the liver seemed to confirm this, showing multiple low attenuation lesions, but also revealed abnormal hepatic venous anatomy with a strictured inferior vena cava; blood circumnavigated the stricture via collateral circulation from the middle hepatic vein to the right hepatic vein and then into the suprahepatic inferior vena cava. There was no acute thrombus, but these collateral vessels represented possible previous hepatic venous thrombosis and chronic venoocclusive liver disease.

Magnetic resonance cholangiopancreatography showed a normal biliary tree. Despite intravenous antibiotics he continued to have fevers, right upper quadrant pain and an elevated C-reactive protein. Positron emission tomography with computed tomography scanning showed diffuse uptake throughout the liver. A liver biopsy was performed (Figure;  H&E Stain, magnification 200×).

What does the liver biopsy show? What is the differential diagnosis for this man’s liver disease?

To find out the diagnosis, read the full case in Gastroenterology or download our Clinical Image Challenge app through AGA App Central, which features new cases each week. Sort and filter by organ, most popular or favorites. AGA App Central is available in both the Apple App Store and Google Play.