Multimodality Imaging of Liver Infections: Differential Diagnosis and Potential Pitfalls

An Imported Case of Gigantic Amoebic Liver Abscess in a 24-Year-Old Woman in Singapore

A liver abscess can be due to several different microbiological aetiologies. While pyogenic liver abscess is most frequently encountered, amoebic liver abscess and hydatid cyst caused by the parasites, Entamoeba histolytica and Echinococcus granulosus, respectively, should be considered whenever there is epidemiological exposure. As parasitic infections are now rarely seen in clinical practice in developed countries with improvement in sanitation, lack of clinical experience in managing amoebic liver abscesses and overlapping clinical and imaging features between amoebic and pyogenic liver abscesses may lead to delay in diagnosis. In particular, although amoebic liver abscesses respond well to treatment if diagnosed early, they can progress and rupture with high mortality if treatment is delayed. Hence, early diagnosis and prompt initiation of antimicrobials are crucial to prevent complications and death. This case report highlights a case of a very large 21 cm ALA in a young lady to illustrate the challenges faced during diagnostic evaluation.

New-onset hepatic lesions in oncological patients: A challenging diagnosis

The appearance of new-onset liver lesions is frequent during imaging follow-up of oncological patients. Most of these lesions will be metastases. But in the presence of atypical radiological findings, there are other diagnoses to consider. Hepatic abscesses, focal nodular hyperplasia-like in patients treated with platinum salts, or hepatocarcinoma in cirrhotic patients are examples of lesions that may appear in the imaging follow-up and should not be confused with metastases. It is essential to establish the nature of the lesion as this will determine the therapeutic management and might avoid unnecessary invasive procedures. The evaluation of previous radiological studies and the global vision of the patient will be primordial. While liver MRI is mainly the indicated imaging technique for these cases, sometimes a biopsy will be unavoidable. In this article, we will discuss through clinical cases some new-onset liver lesions in oncological patients that generated diagnostic doubts and will explain how to orient the diagnosis.

The Clinical Picture Caused by Fasciola gigantica: Analysis of 3250 Patients Along the 1995-2019 Countrywide Spread in Vietnam

Background

Fasciola gigantica is the causal agent of human fascioliasis, which is emerging in southern Asia and increasingly reported in Africa. Unfortunately, knowledge of the clinical picture by F gigantica is insufficient, because of the sporadic individual case reports, or few case series of short number of patients from areas where the 2 genetically pure fasciolid species geographically overlap and specific causality was not verified.

Methods

The clinical picture is assessed from patients examined in well-equipped hospitals of big cities in Vietnam. Records of 3250 Fasciola-infected patients were registered in individual cards and a database for their complete analysis was constructed. Case profile was based on typical symptoms, blood eosinophilia, serological test, imaging techniques, Kato-Katz test, and ex juvantibus confirmation. Anamnesis furnished information about place of residence, professional activities, and infection source.

Results

Symptoms, signs, and manifestations, including neurological, meningeal, neuropsychic, and ocular disorders, are analyzed according to frequency, sex, and age groups. Early patient diagnosis and treatment facilitated by radio broadcasting underlie differences between serological positivity, coprological positivity, and liver lesions and explain the absence of severe long-term complications and posttreatment sequelae.

Conclusions

This is the first sufficiently wide study of the clinical picture caused by F gigantica. The assessment has been made in a population without previous contact with fascioliasis and shows that F gigantica (and F gigantica-like hybrids) do not cause clinical pictures different from those caused by Fasciola hepatica. This clinical picture will be useful for physicians and health officers in endemic areas of Asia and Africa.

Equilibrium phase images of the liver using a contrast-enhancement boost instead of the portal vein phase

BACKGROUND

Three-phase dynamic computed tomography imaging is particularly useful in the liver region. However, dynamic imaging with contrast media has the disadvantage of increased radiation exposure due to multiple imaging sessions. We hypothesized that the contrast enhancement boost (CE-boost) technique could be used to enhance the contrast in equilibrium phase (EP) images and produce enhancement similar to that of portal vein phase (PVP) images, and if this is possible, EP imaging could play the same role as PVP imaging. We also speculated that this might allow the conversion of three-phase dynamic imaging to biphasic dynamic imaging, reducing patients’ radiation exposure.

AIM

To determine if the CE-boost of EP, CE-boost (EP) is useful compared to a conventional image.

METHODS

We retrospectively analyzed the cases of 52 patients who were diagnosed with liver cancer between January 2016 and October 2022 at our institution. From these computed tomography images, CE-boost images were generated from the EP and plane images. We compared the PVP, EP, and CE-boost (EP) for blood vessels and hepatic parenchyma based on the contrast-to-noise ratio (CNR), signal-to-noise ratio, and figure-of-merit (FOM). Visual assessments were also performed for vessel visualization, lesion conspicuity, and image noise.

RESULTS

The CE-boost (EP) images showed significant superiority compared to the PVP images in the CNR, signal-to-noise ratio, and FOM except regarding the hepatic parenchyma. No significant differences were detected in CNR or FOM comparisons within the hepatic parenchyma (P = 0.62, 0.67). The comparison of the EP and CE-boost (EP) images consistently favored CE-boost (EP). Regarding the visual assessment, the CE-boost (EP) images were significantly superior to the PVP images in lesion conspicuity, and the PVP in image noise. The CE-boost (EP) images were significantly better than the EP images in the vessel visualization of segmental branches of the portal vein and lesion conspicuity, and the EP in image noise.

CONCLUSION

The image quality of CE-boost (EP) images was comparable or superior to that of conventional PVP and EP. CE-boost (EP) images might provide information comparable to the conventional PVP.

Vascular penetration sign: dual-phase enhanced CT manifestations of atypical liver abscess caused by Klebsiella pneumoniae

OBJECTIVES

The aim of this study was to investigate the multislice spiral computed tomography (MSCT) features of atypical liver abscesses caused by Klebsiella pneumoniae (KP).

METHODS

A retrospective review was conducted on patients with atypical KP-caused liver abscesses, as verified by biopsy or surgery, from October 2019 to December 2023. All patients underwent dual-phase enhanced CT scan, and MSCT findings were analysed.

RESULTS

Seventy-two patients (58.5 ± 12.3 years, 43 males, 29 females) with atypical KP-induced liver abscess and 115 lesions were identified. Vascular penetration was detected in twelve lesions, presenting as vascular thickening, indistinct margins, and irregular invasive alterations. Among them, three lesions were initially misdiagnosed as primary hepatic lymphoma (PHL). Additionally, 50 lesions exhibited imaging patterns such as the "honeycomb", "petal", or "cluster" signs, and 40 lesions showed "lesion shrinkage" sign. Transient abnormal enhancement in hepatic parenchyma was observed in 83 lesions.

CONCLUSION

Vascular penetration with inflammatory infiltration might be a crucial sign in the diagnosis of atypical liver abscess caused by KP; correctly recognising this sign could reduce misdiagnosis.

KEY POINTS

Question Early imaging diagnosis of atypical liver abscesses caused by Klebsiella pneumoniae is significant because microbiology or blood cultures are time-consuming and may delay appropriate treatment. Findings The vascular penetration sign was noted in some Klebsiella pneumoniae atypical liver abscesses and play a vital role in the diagnosis of this disease. Clinical relevance The newly discovered vascular penetration sign in this study is an important sign for identifying atypical liver abscesses caused by Klebsiella pneumoniae. Accurate identification of this sign facilitates early clinical diagnosis and diminishes the risk of misdiagnosis.

Klebsiella liver phlegmon mimicking a solid liver tumour

Introduction

This case examines the sonographic and clinical challenge of diagnosing a Klebsiella pnumoniae pyogenic liver abscess with systemic metastatic infection.

Case Description

The patient in this case study is an 81-year-old man who presented with intermittent rigors. Following radiological and clinical assessments, a Klebsiella pnumoniae pyogenic liver abscess, with evidence of systemic metastatic infection, was diagnosed. Sonographic features of the liver abscess were atypical for a cystic lesion and instead appeared as a solid mass, raising the possibility of malignancy. Treatment of intravenous ceftriaxone infusions resulted in full resolution of the liver lesion.

Discussion

The discussion criticises the terminology when describing hepatic lesions, which result from a Klebsiella pnumoniae infection. The term hepatic phlegmon is appropriate when a liver lesion caused by bacterial infection demonstrates a solid appearance on radiologic imaging. The term hepatic abscess is appropriate in cases where liver lesions caused by bacterial infection demonstrate a fluid filled core on radiologic imaging. Differentiation of these terms is important when treating the underlying lesion as a phlegmon, in contrast to an abscess, cannot be drained because it contains no pus. The variable sonographic appearances of Klebsiella pnumoniae pyogenic abscesses were also examined. Despite reported sonographic appearances in the literature, none are sufficient to distinguish a pyogenic liver abscess from malignancy without further investigation.

Conclusion

Ultrasound operators should be aware of the variable sonographic appearances of a Klebsiella pnumoniae liver abscess and how these features, combined with non-homogenous terminology, can obfuscate the correct diagnosis.

Discontinuous peripheral enhancement of focal liver lesions on CT and MRI: outside the box of typical cavernous hemangioma

The discontinuous peripheral enhancement is a pattern of enhancement usually attributed to typical cavernous hemangioma, that is the most common benign solid lesion of the liver. The discontinuous peripheral enhancement, however, may be encountered in many other benign and malignant focal liver lesions as an atypical presentation or evolution, and hemangiomas with discontinuous peripheral hyperenhancement on hepatic arterial phase may not always have the typical post-contrast pattern on portal venous and delayed phases. Therefore, abdominal radiologists may be challenged in their practice by lesions with discontinuous peripheral enhancement. This pictorial essay aims to review the spectrum of benign and malignant focal liver lesions that may show discontinuous peripheral enhancement. A particular point of interest is the diagnostic tree pathway that may guide the radiologists in the differential diagnosis.

Hepatic cysts: a survival guide

Hepatic cysts are quite common in the daily practice of radiologists and are generally described as simple cysts or as cystic lesions sparsely distributed throughout the parenchyma, often without the discrimination they merit. Simple cysts have, by definition, thin walls, one or two thin septa, and homogeneous fluid content. Such cysts include congenital epithelial cysts, biliary hamartomas, and peribiliary cysts, as well as those representing Caroli's disease or polycystic liver disease. Complex cysts have variable walls, septa, and contents. They also have various etiologies. A detailed assessment of the clinical history and imaging characteristics can assist in making the diagnosis and choosing a course of clinical management. In this review, hepatic cysts are divided, for educational purposes, into five categories: congenital, traumatic, neoplastic, inflammatory, and miscellaneous.

Cystic lesions and their mimics involving the intrahepatic bile ducts and peribiliary space: diagnosis, complications, and management

Biliary and peribiliary cystic lesions represent a diverse group of abnormalities, often discovered incidentally during imaging for unrelated conditions. These lesions, typically asymptomatic, necessitate precise imaging modalities to characterize their nature and determine subsequent clinical actions, such as follow-up imaging, biopsy, or surgical referral. The anatomic location of these cystic lesions, whether biliary or peribiliary, influences both diagnostic and prognostic outcomes. Biliary cystic lesions, such as mucinous cystic neoplasms, intraductal papillary neoplasms of the bile duct, and Caroli disease, require careful monitoring due to their propensity to develop malignancy. In contrast, peribiliary cysts are often associated with chronic liver disease and may indicate disease progression through a gradual increase in cyst size. Accurate differentiation of these lesions from other clinical entities that have overlapping features on imaging, such as microabscesses, bilomas, Langerhans cell histiocytosis, neurofibromatosis, and vascular anomalies such as cavernous transformation of the portal vein, is essential given the divergent management for each. This article focuses on intrahepatic biliary and peribiliary cystic lesions and their mimics, highlighting their imaging characteristics with an emphasis on magnetic resonance imaging and magnetic resonance cholangiopancreatography, differential diagnosis, potential associated complications, and clinical management.

A multidisciplinary analysis of over 53,000 fascioliasis patients along the 1995-2019 countrywide spread in Vietnam defines a new epidemiological baseline for One Health approaches

Fascioliasis, only foodborne trematodiasis of worldwide distribution, is caused by Fasciola hepatica and F. gigantica, liver flukes transmitted by freshwater snails. Southern and southeastern Asia is an emerging hot spot of F. gigantica, despite its hitherto less involvement in human infection. In Vietnam, increasing cases have been reported since 1995, whereas only sixteen throughout 1800-1994. A database was created to include epidemiological data of fascioliasis patients from the 63 Vietnam provinces throughout 1995-2019. Case profiles were based on serology, symptoms, eosinophilia, imaging techniques, stool egg finding, and post-specific-treatment recovery. Radio broadcasting about symptoms and costless diagnosis/treatment led patients to hospitals after symptom onset. Yearly case numbers were modelled and spatio-temporally analyzed. Missing data and confounders were assessed. The countrywide spread has no precedent. It started in the central coast, including 53,109 patients, mostly adults and females. Seasonality, linked to vegetable consumption, peaks in June, although the intensity of this peak differs according to relief/climatic zones. Incidence data and logistic regression curves are obtained for the first time in human fascioliasis. Fasciolid hybrids accompanying the spreading F. gigantica flukes, and climate change assessed by risk index correlations, are both ruled out as outbreak causes. Human-guided movements of livestock from an original area prove to be the way used by fasciolids and lymnaeid vectors to expand geographically. Radix viridis, a highly efficient transmitting and colonizing vector, played a decisive role in the spread. The use of irrigated crop fields, widely inhabited by R. viridis, for livestock grazing facilitated the transmission and spread of the disease. General physician awareness and diagnostic capacity improvement proved the successful impact of such knowledge transfer in facilitating and increasing patient infection detection. Information, education and communication to the public by radio broadcasting demonstrated to be very helpful. Fasciola gigantica is able to cause epidemic and endemic situations similar to F. hepatica. The magnitude of the human outbreak in Vietnam is a health wake-up call for southern and southeastern countries of Asia which present the highest human population densities with increasing food demands, uncontrolled livestock inter-country exchange, foreign import practices, and monsoon's increasing climate change impact.

Clinical Outcomes of Liver Abscesses in Adults: A 10-Year Experience at a Tertiary Care Center in Northern India

Purpose Hepatic abscesses remain a significant clinical challenge due to high morbidity and mortality. This research aims to examine the etiological spectrum, management approaches, clinical features, and results in hepatic abscesses in a tertiary care facility in northern India, emphasizing the distinctions among pyogenic liver abscesses (PLAs) and amoebic liver abscesses (ALAs). Methods This retrospective study was done at GSVM Medical College, Kanpur, analyzing 725 patients with hepatic abscesses over a 10-year period. Patients were included based on confirmed diagnoses of ALAs or PLAs through clinical, serological, and microbiological evidence. Data on demographics, clinical presentation, imaging findings, laboratory results, and management approaches were extracted from hospital records. IBM SPSS Statistics for Windows, Version 23 (Released 2015; IBM Corp., Armonk, New York, United States) was employed for statistical analysis, and continuous variables were displayed accordingly as means or medians and categorical variables as frequencies. Subgroup analyses were conducted based on abscess characteristics, including size, location, and etiology. Results Of the 725 patients analyzed, the mean age was 42.7 ± 15.8 years, with men comprising 85.93% of the cohort. ALAs accounted for 82.3% of cases, while PLAs comprised 12%. PLA cases frequently involved Gram-negative pathogens, such as Escherichia coli and Klebsiella pneumoniae, with 64% of PLA patients exhibiting positive pus or blood cultures. Common presenting symptoms included abdominal pain (87%) and fever (84.5%). Significant comorbidities included alcoholism (43.6%) and diabetes mellitus (34.2%). Right lobe involvement was predominant (75.9%), and multiple abscesses were noted in 47.5% of patients. Complications included pleural effusion (53.9%), abscess rupture (16.3%), and systemic inflammatory response syndrome (25.7%). Management strategies comprised antibiotics, percutaneous catheter drainage (74.8%), and needle aspiration (43.4%), with conservative treatment being effective in smaller abscesses. Mortality rates were low, at 1.6% for ALAs and 1.5% for PLAs. Hospital stays were shorter for PLA cases (median: five days) compared to ALAs (median: 7.3 days). Conclusion This study underscores the predominance of ALAs in endemic regions like India and highlights the significant role of Gram-negative bacteria in PLAs. Tailored management strategies, including percutaneous interventions and early antibiotic therapy, were associated with favorable outcomes and low mortality. However, the emergence of antimicrobial resistance in PLAs warrants robust antimicrobial stewardship. Public health measures focused on sanitation and clean water are critical to reducing the prevalence of ALAs.

Peribiliary cysts: Two case reports

Peribiliary cysts are an incidental finding in patients with advanced liver disease. They were found to be common in fibrocystic disorders such as autosomal dominant polycystic kidney disease and polycystic liver disease, as well as cirrhotic livers. They result from obstruction-induced cystic dilatation of the peribiliary glands. We report in this article the case of 2 patients, aged 41 and 71, smokers and chronic alcoholics, admitted for febrile cholestatic jaundice, for which MRI revealed the presence of peribiliary cysts.

Computed Tomographic Findings in Dogs with Hepatic Bacterial Parenchymal Infection and Abscessation

Bacterial liver parenchymal infections in dogs are rarely documented, and their imaging characteristics are scarce in the veterinary literature, especially in Computed Tomography (CT). This retrospective multicentric study aimed to describe the CT characteristics of parenchymal bacterial liver infection and abscessation in dogs and compare them with the human literature. Twenty dogs met the inclusion criteria. All dogs, except one, showed discrete hepatic lesions consistent with pyogenic liver abscess (19/20). A single case showed diffuse liver changes, which was diagnosed with granulomatous bacterial hepatitis (1/20). Multifocal lesions were associated with the presence of abdominal pain (p = 0.023). CT characteristics of pyogenic liver abscesses in our study resemble those described in the human literature, with multifocal (14/19) or single (5/19), round or ovoid (19/19), hypoattenuating hepatic lesions, which are better visualised in post-contrast images. Pyogenic liver abscesses can also show features such as the "cluster sign" (8/19), transient arterial segmental enhancement (6/10), rim enhancement (6/19), and intralesional gas (4/19). Additional CT findings, such as local lymphadenomegaly (18/20), peritoneal fat stranding (14/20), and peritoneal fluid (13/20), are also commonly observed.

MRI radiomics model differentiates small hepatic metastases and abscesses in periampullary cancer patients

This multi-center, retrospective study focused on periampullary cancer patients undergoing MRI for hepatic metastasis and abscess differentiation. T1-weighted, T2-weighted, and arterial phase images were utilized to create radiomics models. In the training-set, 112 lesions in 54 patients (median age [IQR, interquartile range], 73 [63-80]; 38 men) were analyzed, and 123 lesions in 55 patients (72 [66-78]; 34 men) comprised the validation set. The T1-weighted + T2-weighted radiomics model showed the highest AUC (0.82, 95% CI 0.75-0.89) in the validation set. Notably, < 30% T1-T2 size discrepancy in MRI findings predicted metastasis (Ps ≤ 0.037), albeit with AUCs of 0.64-0.68 for hepatic metastasis. The radiomics model enhanced radiologists' performance (AUCs, 0.85-0.87 vs. 0.80-0.84) and significantly increased diagnostic confidence (P < 0.001). Although the performance increase lacked statistical significance (P = 0.104-0.281), the radiomics model proved valuable in differentiating small hepatic lesions and enhancing diagnostic confidence. This study highlights the potential of MRI-based radiomics in improving accuracy and confidence in the diagnosis of periampullary cancer-related hepatic lesions.

Characteristics of imaging in hepatic inflammatory pseudotumors: a comparison between IgG4-related and IgG4-unrelated cases

OBJECTIVES

The objective of this study was to examine the imaging features of hepatic inflammatory pseudotumors (IPTs) associated with IgG4-related and IgG4-unrelated conditions and to enhance the approach toward distinguishing between these two types of IPTs.

METHODS

A retrospective study was conducted, involving 20 patients diagnosed with hepatic IPTs. Imaging procedures were conducted within a timeframe of 4 weeks prior to hepatectomy or biopsy. The imaging features were then analyzed and compared using chi-squared analysis.

RESULTS

Seventeen (81.0%) IPTs were located in the hepatic subcapsular area; six (66.7%) IgG4-related IPTs were distributed around the hepatic hilum; and eleven (91.7%) IgG4-unrelated and three (33.3%) IgG4-related IPTs had unclear boundaries. All lesions exhibited similar characteristics in CT scans, T1-weighted imaging (T1WI), T2-weighted imaging (T2WI), and diffusion-weighted imaging (DWI), with the apparent diffusion coefficient (ADC) values slightly higher than the surrounding liver tissue. Delayed hypoenhancement, observed in five cases (55.6%), was exclusively present in IgG4-related IPTs. The remaining IPT lesions displayed progressive enhancement, septal and marginal enhancement, and persistent enhancement. Central enhancement was absent in three IgG4-related IPTs (33.3%) and ten IgG4-unrelated IPTs (83.3%). The duct-penetrating sign was identified in two IgG4-unrelated IPTs (16.7%) and seven IgG4-related IPTs (77.8%). Furthermore, seven patients with IgG4-related IPTs had additional lesions outside the liver.

CONCLUSIONS

IgG4-related lesions are frequently found in the vicinity of the hepatic hilum; they display the duct-penetrating sign and affect other organs as well. Both groups exhibited progressive or persistent contrast enhancement in typical IPT lesions, but delayed hypoenhancement was only observed in the IgG4-related IPT group. IgG4-unrelated IPT lesions often exhibited indistinct boundaries lacking central enhancement.

CRITICAL RELEVANCE STATEMENT

Differences in imaging features differentiate IgG4-related and -unrelated inflammatory pseudotumors (IPT). IgG4-related lesions are frequently near the hepatic hilum, display duct-penetrating sign, and affect other organs. Only the IgG4-related group demonstrated delayed hypoenhancement. IgG4-unrelated IPT lesions often exhibited indistinct boundaries lacking central enhancement.

KEY POINTS

Compared with IgG 4-unrelated IPTs, IgG4-related IPTs show delayed hypoenhancement and affect other organs. IgG4-unrelated IPTs have unclear boundaries and lack central enhancement. Improved IPT diagnostic capabilities can help minimize additional, potentially unnecessary, interventions.

Benign and malignant focal liver lesions displaying rim arterial phase hyperenhancement on CT and MRI

Rim arterial phase hyperenhancement is an imaging feature commonly encountered on contrast-enhanced CT and MRI in focal liver lesions. Rim arterial phase hyperenhancement is a subtype of arterial phase hyperenhancement mainly present at the periphery of lesions on the arterial phase. It is caused by a relative arterialization of the periphery compared with the center of the lesion and needs to be differentiated from other patterns of peripheral enhancement, including the peripheral discontinuous nodular enhancement and the corona enhancement. Rim arterial phase hyperenhancement may be a typical or an atypical imaging presentation of many benign and malignant focal liver lesions, challenging the radiologists during imaging interpretation. Benign focal liver lesions that may show rim arterial phase hyperenhancement may have a vascular, infectious, or inflammatory origin. Malignant focal liver lesions displaying rim arterial phase hyperenhancement may have a vascular, hepatocellular, biliary, lymphoid, or secondary origin. The differences in imaging characteristics on contrast-enhanced CT may be subtle, and a multiparametric approach on MRI may be helpful to narrow the list of differentials. This article aims to review the broad spectrum of focal liver lesions that may show rim arterial phase hyperenhancement, using an approach based on the benign and malignant nature of lesions and their histologic origin. CRITICAL RELEVANCE STATEMENT: Rim arterial phase hyperenhancement may be an imaging feature encountered in benign and malignant focal liver lesions and the diagnostic algorithm approach provided in this educational review may guide toward the final diagnosis. KEY POINTS: Several focal liver lesions may demonstrate rim arterial phase hyperenhancement. Rim arterial phase hyperenhancement may occur in vascular, inflammatory, and neoplastic lesions. Rim arterial phase hyperenhancement may challenge radiologists during image interpretation.

A Case Series and Literature Review of Alveolar Echinococcosis in Kashmir, India: An Emerging Endemic Zone for Echinococcus multilocularis

A prospective study on 110 patients with echinococcosis at Dr. Khuroo's Medical Clinic, Srinagar, Kashmir, India, from March 2019 to April 2024 identified 12 cases (4 males, 8 females; mean age of 46.58 ± 11.97 years) of Alveolar echinococcosis (AE). Two patients were detected through ultrasound examinations carried out for unrelated causes; one presented with features of liver abscess, and nine had pain in the right upper quadrant for a mean period of 2.2 ± 1.79 years. All had the liver as the primary organ involved, with 15 tumor masses of a mean maximum diameter of 9.22 ± 3.21 cm and volume of 426 ± 374.61 cm3. Tumors placed centrally had invaded vessels and the biliary tract in eight patients, and those placed peripherally had invaded the liver capsule and adjacent organs in nine patients. Histologic examination of liver biopsies or resected organs revealed necrotic lesions, calcifications, and granulomatous inflammation with slender, thin-walled vesicles of bizarre configuration that stained strongly eosinophilic with periodic acid Schiff. Two patients had segmental liver resections; one was treated with liver aspiration, while the other nine with advanced disease received chemotherapy with albendazole along with praziquantel. Patients showed clinical improvement on a median follow-up of 12 months (range 1 to 60 months); however, MRI T2-weighted images and 18F-FDG-PET-CECT scans in two patients showed active disease on follow-up at one and five years, respectively. A systematic review detected 146 cases of AE in India from 1980 to April 2024. Twenty cases were from foreign countries, mostly from Central Asian republics, and 118 (93.65%) of the remaining 126 Indian patients were permanent residents of Kashmir Valley. The disease affected a population of 79,197 residing in 22 villages from 5 border districts of the valley. These villages were either high in or adjacent to the Himalayan mountain range. Disease prevalence in the affected population was 146.47/105 (males 131.53/105 and females 163.18/105) and the incidence was 12.41/105/year (males 11.16/105/year and females 13.81/105/year). Possible causes of the emergence of AE are discussed, and future directions for research to face this challenge arebeen identified.

Human fascioliasis emergence in southern Asia: Complete nuclear rDNA spacer and mtDNA gene sequences prove Indian patient infection related to fluke hybridization in northeastern India and Bangladesh

Fascioliasis is a snail-borne zoonotic disease with impact on the development of human subjects and communities. It is caused by two liver-infecting fasciolid trematode species, the globally-distributed Fasciola hepatica and the Africa/Asia-restricted but more pathogenic, larger F. gigantica. Fasciola gigantica is the cause of endemicity in livestock throughout the warm lowlands from Pakistan to southeastern Asia since old times. Human fascioliasis is emerging in this region at present, with an increase of patient reports. Complete sequences of rDNA ITS-1 and ITS-2 spacers and mtDNA nad1 and cox1 genes were obtained from fasciolid eggs found in the endoscopic bile aspirate from a patient of Arunachal Pradesh, northeastern India. Egg measurements, pronounced ITS heterozygosity, and pure F. gigantica mtDNA haplotypes demonstrate an infection by a recent F. gigantica-like hybrid. Sequence identities and similarities with the same DNA markers found in livestock from Bangladesh prove the human-infecting fasciolid to present identical ITSs and nad1 haplotypes and only one silent transversion in cox1 when compared to a widely-spread combined haplotype in animals. In northeastern India and Bangladesh, human fascioliasis emergence appears linked to increasing livestock prevalences due to: ruminant importation from other countries because of the increasing demand of rapidly growing human populations; numerous livestock movements, including transborder corridors, due to the uncontrolled small-scale household farming practices; and man-made introduction of F. hepatica with imported livestock into an area originally endemic for F. gigantica leading to frequent hybridization. Sequences, phylogenetic trees, and networks indicate that the origins of intermediate/hybrid fasciolids and factors underlying human infection risk differ in eastern and western South Asia. The emergence scenario in southern China and Vietnam resembles the aforementioned of northeastern India and Bangladesh, whereas in Pakistan it is linked to increasing monsoon rainfall within climate change combined with an impact of an extensive irrigation system. Past human-guided movements of pack animals along the western Grand Trunk Road and the eastern Tea-Horse Road explain the F. gigantica mtDNA results obtained. Physicians should be aware about these emerging scenarios, clinical pictures, diagnostic techniques and treatment. Government authorities must appropriately warn health professionals, ensure drug availability and improve livestock control.

Diagnostic approach to splenic lesions

BACKGROUND

Splenic lesions are rare and mostly incidental findings on cross-sectional imaging. Most lesions are of benign nature and can be correctly identified based on imaging characteristics. Further, invasive evaluation is only necessary in cases of splenic lesions with uncertain or potentially malignant etiology.

METHOD

While in most cases a correct diagnosis can be made from computed tomography (CT), (additional) magnetic resonance imaging (MRI) can aid in the identification of lesions. As these lesions are rare, only a few of the differential diagnoses are regularly diagnosed in the clinical routine.

RESULT AND CONCLUSION

This review presents the differential diagnoses of splenic lesions, including imaging characteristics and a flowchart to determine the right diagnosis. In conjunction with laboratory results and clinical symptoms, histological workup is necessary only in a few cases, especially in incidental findings. In these cases, image-guided biopsies should be preferred over splenectomy, if possible.

KEY POINTS

· Splenic lesions are rare and are usually incidental findings on abdominal imaging. · CT imaging and MRI imaging are the diagnostic tools of choice for the further workup of splenic lesions. · Based on their image morphological characteristics, a large number of splenic lesions can be assigned to one entity and do not need histological analysis.

CITATION FORMAT

· Krähling H, Seidensticker M, Heindel WL et al. Diagnostic approach to splenic lesions. Fortschr Röntgenstr 2024; 196: 573 - 581.

Imaging of abdominopelvic oncologic emergencies

With advancements in cancer treatment, the survival rates for many malignancies have increased. However, both the primary tumors and the treatments themselves can give rise to various complications. Acute symptoms in oncology patients require prompt attention. Abdominopelvic oncologic emergencies can be classified into four distinct categories: vascular, bowel, hepatopancreatobiliary, and bone-related complications. Radiologists need to be familiar with these complications to ensure timely diagnosis, which ultimately enhances patient outcomes.

Liver abscess after endoscopic sleeve gastroplasty: A case report

Endoscopic sleeve gastroplasty is a minimally invasive procedure for the treatment of obesity. The procedure is generally safe and well-tolerated, but major adverse events occur in up to 3% of patients. Perigastric abscess is a potential complication caused by postprocedural gastric leak. To the best of our knowledge, no cases of hepatic abscess (HA) following endoscopic sleeve gastroplasty have been reported, while HA is a well-known complication of laparoscopic sleeve gastrectomy. We report the case of a patient who developed a liver abscess 2 weeks after endoscopic sleeve gastroplasty. The patient improved with administration of intravenous antibiotics and endoscopic drainage.

Hepatic abscessation in dogs: A multicenter study of 56 cases (2010-2019)

OBJECTIVE

To investigate the clinical findings, treatment strategies, and outcomes in dogs with confirmed hepatic abscessation.

DESIGN

Retrospective cohort study from 2010 to 2019.

SETTING

Multicenter study.

ANIMALS

Fifty-six client-owned dogs with hepatic abscessation confirmed by culture, cytology, or histopathology.

MEASUREMENTS AND MAIN RESULTS

Dogs were presented for lethargy (39/56), hyporexia (31/56), and vomiting (26/56). Abnormal physical examination findings included increased temperature (41/56) and abdominal pain (22/54). CBCs revealed neutrophilia (31/49), toxic changes (25/49), anemia (28/49), and thrombocytopenia (23/49). Biochemical analyses revealed increased alkaline phosphatase (45/50), increased alanine aminotransferase (40/50), hypoalbuminemia (25/48), and hyperbilirubinemia (19/49). Hypoglycemia was found in 13 of 49 dogs. Hepatic abscesses ranging from 0.5 to 15 cm in diameter were identified ultrasonographically in 37 of 48 dogs; 19 of 37 had solitary abscesses, and 18 of 37 had multifocal abscessation. Escherichia coli was the most commonly cultured organism, isolated in 18 of 42 cases. Histopathology revealed underlying hepatic neoplasia in 10 of 47 dogs. Surgical management was performed in 41 of 49 dogs, and 35 of 41 survived to discharge. Medical management was performed in 8 of 49 dogs, and 5 of 8 survived to discharge. With univariate analysis, hypoglycemia and multifocal abscessation were associated with decreased odds of survival (odds ratio [OR]: 0.2, 95% confidence interval [CI]: 0.03-0.9, P = 0.04; OR: 0.07, 95% CI: 0.01-0.6, P = 0.02, respectively). With multivariate analysis, only multifocal abscessation was associated with decreased odds of survival (OR: 0.09, 95% CI: 0.01-0.87, P = 0.04).

CONCLUSIONS

Hepatic abscessation, although rare, should remain a differential diagnosis for dogs presenting with nonspecific clinical signs and increase liver enzyme activities, especially with concurrent increased temperature and neutrophilia. Rate of survival to discharge for dogs in this study was consistent with previously reported survival rates, with 40 of 56 (71%) of the total population surviving to discharge. No variables assessed were able to predict survival to discharge; however, hypoglycemia and multifocal abscessation should be assessed in larger populations to determine prognostic significance.

Pyogenic liver abscess complicated with endogenous endophthalmitis caused by Klebsiella pneumoniae: A case report and Literature Review

OBJECTIVE

Pyogenic liver abscess (PLA) is a common surgical infectious disease caused by various pathogens. Klebsiella pneumoniae is a relatively recent cause, often affecting patients with low immunity. Endogenous endophthalmitis (EE), a rare and serious complication of PLA, may appear with eye symptoms before PLA. By reviewing a case of Klebsiella pneumoniae-induced PLA complicated with EE, we want to summarize the information about the characteristics, causes, and complications of PLA based on the literature review.

METHODS

This case report describes a 37-year-old male who had fever high to 39°C for 10 days experienced blurred vision followed by nonlight perception vision. He reported a history of diabetes irregularly taking oral medications and insulin therapy. Imaging examination found a large low-density area in the right lobe of the liver with an unclear border and vague surrounding fat gap. The blood culture was not positive. The culture of the drainage fluid from the liver puncture showed Klebsiella pneumonia. Blood and liver puncture drainage fluid were sent for microbial high-throughput gene detection with next-generation sequencing technology (NGS), which confirmed the diagnosis of Klebsiella pneumoniae-induced PLA complicated with EE.

RESULTS

The patient's surgical incision had healed well at discharge, and he could feel light at his left eye. But the patient was lost to follow-up since the third month after discharge.

CONCLUSION

By reviewing this case and summarize the information about the characteristics, causes, and complications of PLA based on the literature review, we concluded that it is necessary to promptly perform liver puncture drainage and empirically use antibiotics for patients with PLA, especially those with poor glycemic control, to avoid serious complications such as EE.

The influence of early adoption of nonenhanced computed tomography on management of patients with pyogenic liver abscess

Background and Aim

A pyogenic liver abscess (PLA) is an infectious disease with high in-hospital mortality. It has no specific symptoms and is difficult to be diagnosed early in the emergency department. Ultrasound is commonly used to detect PLA lesions of PLA, but its sensitivity can be affected by lesion size, location, and clinician experience. Therefore, early diagnosis and prompt treatment (especially abscess drainage) are crucial for better patient outcomes and should be prioritized by clinical physicians.

Methods

We conducted a retrospective study to compare the effect of early and late (i.e., receiving CT scanning within 48 h and >48 h after admission) adoption of nonenhanced computed tomography (CT) scanning regarding the hospitalization days and interval between admission and drainage of patients with PLA.

Results

This study included 76 hospitalized patients with PLA in the Department of Digestive Disease of Xiamen Chang Gung Hospital in China who underwent CT examinations from 2014 to 2021. We conducted CT scans on 56 patients within 48 h of admission and on 20 patients more than 48 h after admission. The early CT group had a significantly shorter hospitalization length compared with the late CT group (15.0 days vs. 20.5 days; P = 0.035). Besides, the median time to initiate drainage after admission was also significantly shorter in the early CT group than in the late CT group (1.0 days vs. 4.5 days; P < 0.001).

Conclusion

Early CT scanning within 48 h of admission may aid in early PLA diagnosis and benefit disease recovery, as revealed by our findings.

Pediatric Liver Abscess: Outcomes of Protocol-based Management and Predictors of Poor Outcome

BACKGROUND

Liver abscess (LA) is an important cause of morbidity in children, especially in tropical countries. There is a paucity of data in pediatric LA with no standard guidelines regarding the best modality of treatment and drainage. With a large influx of patients at our center and protocol-based management; we aimed to study clinic-radiologic profile, risk factors, complications and outcomes of children with liver abscess and assessed possible predictors for poor outcomes.

MATERIALS AND METHODS

This retrospective observational study was conducted from January 2019 to September 2019 at a tertiary care hospital in India. Records of all children (<12 years of age) with ultrasonographically diagnosed liver abscess were accessed for clinic-radiological and demographic profile, laboratory investigations, treatment, complications and outcomes. Patients were categorized into favorable or unfavorable groups based on predefined criteria and were compared for possible predictors of poor outcomes. Outcomes for the protocol-based management were analyzed.

RESULTS

There were 120 cases of pediatric liver abscess with a median age of 5 years at presentation. The commonest clinical features were fever (100%) and pain in the abdomen (89.16%). The majority of liver abscesses were solitary (78.4%) and in the right lobe (73.3%). Malnutrition was present in 27.5%, overcrowding for 76.5% of patients and worm infestation in 2.5% of patients. Age-related leukocytosis (P = 0.004), neutrophilia (P = 0.013), elevated Aspartate transaminase (P = 0.008), elevated alanine transaminase (P = 0.007) and hypoalbuminemia (P = 0.014) were significantly more in the unfavorable group. Overall, 29.2% of patients underwent conservative management with antibiotics alone, 25.0% underwent percutaneous needle aspiration (PNA), 49.1% underwent ultrasound-guided percutaneous drain (PCD) insertion and open surgical drainage (OSD) was needed in a single patient. The success rate was 100% for conservative management, 76.6% for PNA, 94.7% for PCD and 100% for OSD with an overall mortality of 2.5%.

CONCLUSIONS

Age-related leukocytosis, neutrophilia, elevated aspartate transaminase or alanine transaminase and hypoalbuminemia at presentation are predictors of poor outcomes in pediatric liver abscess. Protocol-based management leads to the appropriate use of PNA and PCD while decreasing mortality and morbidity related to either.

Transjugular intrahepatic portosystemic shunt (TIPS) complications: what diagnostic radiologists should know

Transjugular intrahepatic portosystemic shunt (TIPS) is an effective therapy for portal hypertension complications and can successfully treat variceal bleeding and refractory ascites. Although TIPS is relatively safe, procedural- or shunt-related morbidity can reach 20%, and procedural complications have a fatality rate of 2%. Delayed recognition and treatment of TIPS complications can lead to life-threatening clinical scenarios. Complications can vary from stent migration or malpositioning to nontarget organ injury, TIPS dysfunction, encephalopathy, or liver failure. This review aims to outline the role of diagnostic radiology in assessing post-TIPS complications.

Cystic liver lesions: a pictorial review

Hepatic cysts (HC) are sac-like structures mainly filled with liquid and showing a distinct membrane. They are usually found incidentally through imaging. A wide spectrum of imaging patterns may be observed for common and uncommon, neoplastic and non-neoplastic diseases. While simple hepatic cysts occur frequently and do not require any treatment or follow-up, non-typical cysts should be carefully analysed to avoid misdiagnosing a lesion that would require appropriate management. Therefore, adequate knowledge of all the relevant imaging patterns is critical to secure an accurate diagnosis. The aim of this review is to describe the imaging features of the different types of hepatic cysts.

Pediatric Hepatic Cystic Lesions: Differential Diagnosis and Multimodality Imaging Approach

When a pediatric hepatic cystic lesion is identified at imaging, the differential diagnosis may be broad, including developmental, infectious, neoplastic, and posttraumatic or iatrogenic causes. The location of a cystic lesion and its number, size, composition, and relationship to the biliary system are features that help in narrowing the differential diagnosis. An incidentally detected simple hepatic cyst is the most commonly encountered. Ciliated foregut cysts are typically located in hepatic segment IVa. The presence of multiple cysts should raise suspicion for fibropolycystic liver disease, a group of related lesions-including biliary hamartoma and choledochal cyst-caused by abnormal embryologic development of the ductal plate. Communication of the cystic lesion with the biliary tree can confirm the diagnosis of choledochal cyst. In a neonate with jaundice, a cystic lesion at the porta hepatis should raise suspicion for choledochal cyst versus cystic biliary atresia. Hepatic abscess can appear cystlike, though typically with internal contents. In an immunocompromised child, multiple cystlike lesions should raise concern for fungal microabscesses. A complex cystic mass in a young child should raise suspicion for mesenchymal hamartoma, which can evolve into undifferentiated embryonal sarcoma if untreated. Hepatic hematoma and biloma can appear cystlike in children with a history of trauma or recent intervention. In neonates with an umbilical vein catheter (UVC), an intrahepatic cyst along the course of the UVC should raise concern for infusate extravasation. Familiarity with imaging findings and clinical features is essential for achieving accurate diagnosis of pediatric hepatic cystic lesions, which in turn can guide appropriate clinical management. Online supplemental material is available for this article. ^©RSNA, 2022.

Imaging of fibropolycystic liver disease

Fibropolycystic liver diseases (FLDs) make up a rare spectrum of heritable hepatobiliary diseases resulting from congenital ductal plate malformations (DPMs) due to the dysfunction of proteins expressed on the primary cilia of cholangiocytes. The embryonic development of the ductal plate is key to understanding this spectrum of diseases. In particular, DPMs can result in various degrees of intrahepatic duct involvement and a wide spectrum of cholangiopathies, including congenital hepatic fibrosis, Caroli disease, polycystic liver disease, and Von Meyenberg complexes. The most common clinical manifestations of FLDs are portal hypertension, cholestasis, cholangitis, and (in rare cases) cholangiocarcinoma. This article reviews recent updates in the pathophysiology, imaging, and clinical management of FLDs.

Imaging Approach to Pulmonary Infections in the Immunocompromised Patient

Pulmonary infections are the major cause of morbidity and mortality in immunocompromised patients and almost one-third of intensive care unit patients with pulmonary infections belong to the immunocompromised category. Multiple organisms may simultaneously infect an immunocompromised patient and the overwhelming burden of mixed infections further predisposes critically ill patients to acute hypoxemic respiratory failure. Notwithstanding that lung ultrasound is coming into vogue, the primary imaging investigation is a chest radiograph, followed by thoracic CT scan. This review based on our experience at tertiary care teaching hospitals provides insights into the spectrum of imaging features of various pulmonary infections occurring in immunocompromised patients. This review is unique as, firstly, the imaging spectrum described by us is categorized on basis of the etiological infective agent, comprehensively and emphatically correlated with the clinical setting of the patient. Secondly, a characteristic imaging pattern is emphasized in the clinical setting-imaging-pattern conglomerate, to highlight the most likely diagnosis possible in such a combination. Thirdly, the simulating conditions for a relevant differential diagnosis are discussed in each section. Fourthly, not only are the specific diagnostic and tissue sampling techniques for confirmation of the suspected etiological agent described, but the recommended pharmaco-therapeutic agents are also enumerated, so as to provide a more robust insight to the radiologist. Last but not the least, we summarize and conclude with a diagnostic algorithm, derived by us from the characteristic illustrative cases. The proposed algorithm, illustrated as a flowchart, emphasizes a diagnostic imaging approach comprising: correlation of the imaging pattern with clinical setting and with associated abnormalities in the thorax and in other organs/systems, which is comprehensively analyzed in arriving at the most likely diagnosis. Since a rapid evaluation and emergent management of such patients is of pressing concern not only to the radiologist, but also for the general physicians, pulmonologists, critical care specialists, oncologists and transplant surgery teams, we believe our review is very informative to a wide spectrum reader audience.

Step-up approach in emphysematous hepatitis: A case report

BACKGROUND

Emphysematous hepatitis (EH) is a rare, rapidly progressive fulminant gas-forming infection of the liver parenchyma. It is often fatal and mostly affects diabetes patients.

CASE SUMMARY

We report a case of EH successfully managed by a step-up approach consisting of aggressive hemodynamic support, intravenous antibiotics, and percutaneous drainage, ultimately followed by laparoscopic deroofing. Of 11 documented cases worldwide, only 1 of the patients survived, treated by urgent laparotomy and surgical debridement.

CONCLUSION

EH is a life-threatening infection. Its high mortality rate makes timely diagnosis essential, in order to navigate treatment accordingly.

Sonographic Detection of Hepatic Abscesses

Hepatic abscesses are masses or lesions within the liver as a response to an infection manifesting into the liver. Hepatic abscess can be a result of other abdominal diseases, such as any biliary tract disease or appendicitis. Because of its inconsistent characteristics in many imaging modalities, its appearance can be mistaken for other pathologies like liver metastasis. With the use of one or more imaging modalities and an imaging-guided biopsy of the targeted lesion, hepatic abscess can be confirmed. The case presents multiple hepatic abscesses throughout the liver with similar imaging characteristics as that of metastasis. Computed tomography (CT), sonography, magnetic resonance imaging, and a biopsy were performed to successfully diagnose the hepatic abscesses.

Imaging Spectrum of Intrahepatic Mass-Forming Cholangiocarcinoma and Its Mimickers: How to Differentiate Them Using MRI

Intrahepatic cholangiocarcinoma (ICC) is the second most common primary hepatic malignancy, with mass-forming growth pattern being the most common. The typical imaging appearance of mass-forming ICC (mICC) consists of irregular ring enhancement in the arterial phase followed by the progressive central enhancement on portal venous and delayed phases. However, atypical imaging presentation in the form of hypervascular mICC might also be seen, which can be attributed to distinct pathological characteristics. Ancillary imaging features such as lobular shape, capsular retraction, segmental biliary dilatation, and vascular encasement favor the diagnosis of mICC. Nevertheless, these radiological findings may also be present in certain benign conditions such as focal confluent fibrosis, sclerosing hemangioma, organizing hepatic abscess, or the pseudosolid form of hydatid disease. In addition, a few malignant lesions including primary liver lymphoma, hemangioendothelioma, solitary hypovascular liver metastases, and atypical forms of hepatocellular carcinoma (HCC), such as scirrhous HCC, infiltrative HCC, and poorly differentiated HCC, may also pose a diagnostic dilemma by simulating mICC in imaging studies. Diffusion-weighted imaging and the use of hepatobiliary contrast agents might be helpful for differential diagnosis in certain cases. The aim of this manuscript is to provide a comprehensive overview of mICC imaging features and to describe useful tips for differential diagnosis with its potential mimickers.

Total Bilirubin Level as a Predictor of Suboptimal Image Quality of the Hepatobiliary Phase of Gadoxetic Acid-Enhanced MRI in Patients with Extrahepatic Bile Duct Cancer

Objective

This study aimed to determine a factor for predicting suboptimal image quality of the hepatobiliary phase (HBP) of gadoxetic acid-enhanced MRI in patients with extrahepatic bile duct (EHD) cancer before MRI examination.

Materials and Methods

We retrospectively evaluated 259 patients (mean age ± standard deviation: 68.0 ± 8.3 years; 162 male and 97 female) with EHD cancer who underwent gadoxetic acid-enhanced MRI between 2011 and 2017. Patients were divided into a primary analysis set (n = 184) and a validation set (n = 75) based on the diagnosis date of January 2014. Two reviewers assigned the functional liver imaging score (FLIS) to reflect the HBP image quality. The FLIS consists of the sum of three HBP features, each scored on a 0–2 scale: liver parenchymal enhancement, biliary excretion, and signal intensity of the portal vein. Patients were classified into low-FLIS (0–3) or high-FLIS (4–6) groups. Multivariable analysis was performed to determine a predictor of low FLIS using serum biochemical and imaging parameters of cholestasis severity. The optimal cutoff value for predicting low FLIS was obtained using receiver operating characteristic analysis, and validation was performed.

Results

Of the 259 patients, 140 (54.0%) and 119 (46.0%) were classified into the low-FLIS and high-FLIS groups, respectively. In the primary analysis set, total bilirubin was an independent factor associated with low FLIS (adjusted odds ratio per 1-mg/dL increase, 1.62; 95% confidence interval [CI], 1.32–1.98). The optimal cutoff value of total bilirubin for predicting low FLIS was 2.1 mg/dL with a sensitivity of 95.1% (95% CI: 88.9–98.4) and a specificity of 89.0% (95% CI: 80.2–94.9). In the validation set, the total bilirubin cutoff showed a sensitivity of 92.1% (95% CI: 78.6–98.3) and a specificity of 83.8% (95% CI: 68.0–93.8).

Conclusion

Serum total bilirubin before acquisition of gadoxetic acid-enhanced MRI may help predict suboptimal HBP image quality in patients with EHD cancer.

Multi-system Klebsiella sepsis: A tale of destruction form lung to eye

Klebsiella pneumoniae, found in the gastrointestinal flora is a causative agent of hospital-acquired infections. Although isolated organ infections are common, reports of multi-system involvement are rare. We report on a susceptible patient presenting with disseminated Klebsiella infection with concurrent multi-organ disease involving the lung, liver, prostate and eye. He recovered after prolonged therapy but suffered from permanent sequalae. Early diagnosis and aggressive therapy is facilitated by awareness and a high degree of suspicion in at-risk patient groups.

Ultrasound and contrast-enhanced ultrasound (CEUS) in infective liver lesions

Infektiöse fokale Leberläsionen (FLL) treten in der klinischen Praxis häufig auf, wobei bakterielle Leberabszesse die Hälfte ausmachen. Eine genaue Diagnose der FLL ist für die Auswahl der am besten geeigneten Therapie und zur Vorbeugung von Komplikationen unerlässlich. Ziel der aktuellen Arbeit ist es, den Nutzen von Ultraschall und kontrastmittelverstärktem Ultraschall (CEUS) zur Erkennung und Charakterisierung infektiöser Leberläsionen zu beschreiben.

Misidentification of hepatic tuberculosis as cholangiocarcinoma: A case report

BACKGROUND

Hepatic tuberculosis (TB) is uncommon clinically. Because of a lack of specific signs, characteristic symptoms and clinical manifestations and because pathological samples are difficult to obtain, hepatic TB is easily missed or misdiagnosed.

CASE SUMMARY

A 62-year-old Chinese man presented with jaundice for 1 wk and no abnormal laboratory tests other than elevated bilirubin, aminotransferases and C-reactive protein. Computed tomography (CT) of the abdomen showed a mass in the left lobe of the liver and hepatic hilum with striped calcified foci. Mild enhancement was visible at the edges, along with extensive intrahepatic biliary ductal dilatation in the right lobe of the liver. In the arterial phase of both CT and magnetic resonance imaging, the main trunk and right branch of the portal artery were partially visualized. Magnetic resonance cholangiopancreatography (MRCP) indicated that the left lobe of the liver and most of the bile ducts in the hilum were not visible. Pathological examination revealed coagulative necrosis, and granulomatous nodules were seen around areas of necrosis; therefore, TB was considered.

CONCLUSION

Hepatic tuberculosis is easily misdiagnosed or missed on imaging. Percutaneous puncture biopsy is the most useful tool for definitive diagnosis.

Amoebic Liver Abscess: Rare Entity in Recent Times

Intestinal amoebiasis and sequelae such as amoebic liver abscess are rarely reported in the era of modern medicine. Atypical presentation of amoebic liver abscess with high false-positive results on serology in endemic regions poses major diagnostic issues in the developing nations of the world. We report a case of amoebic liver abscess and describe the imaging appearances in a 59-year-old female. A detailed medical history was elicited to determine the etiology of amoebic liver abscess. Furthermore, the diagnosis was confirmed based on serological tests. Percutaneous aspiration of the amoebic liver abscess was performed, and treatment was initiated with intravenous metronidazole followed by diloxanide furoate. The patient has been on follow-up since three months with a negative stool examination and with no complaints of recurrence.

Giant haemorrhagic hepatic cyst with flame-like morphology in a patient with polycystic kidney and liver disease

Introduction

Intracystic haemorrhage is a rare complication of hepatic cysts, and is often mistaken for a malignant lesion.

Case Report

A 55-year-old female with a history of polycystic kidney and liver disease presented with a six-month history of abdominal distension, abdominal pain, early satiety, shortness of breath and 5 kg of weight loss. Imaging revealed a 20 cm mixed solid-cystic hepatic lesion containing peripheral avascular mobile echogenic material with a flame-like morphology. After experiencing symptomatic relief from ultrasound-guided aspiration, the patient underwent cyst fenestration for more definitive treatment.

Discussion

Haemorrhagic hepatic cysts are uncommon and may present on imaging as having lace-like retractile clot, internal layering or shading of separating blood products or avascular mobile flame-like excrescences. The presence of avascular mobile flame-like excrescences appears to be a unique feature of haemorrhagic hepatic cysts.

Conclusion

While haemorrhagic hepatic cysts are rare and commonly mistaken for biliary cystadenomas or adenocarcinomas, the identification of particular features on high-resolution magnetic resonance imaging and contrast-enhanced ultrasound can lead to the correct diagnosis.

Epidemiology and risk factors for pyogenic liver abscess in the Calgary Health Zone revisited: a population-based study

Background

Pyogenic liver abscess (PLA), although uncommon in North America, is associated with significant morbidity and mortality. We sought to re-examine the epidemiology, risk factors, and outcomes of PLA in a large, diverse Canadian health zone.

Methods

All Calgary Health Zone (CHZ) residents aged ≥20 with PLA between 2015 and 2017 were identified. Incidence and mortality rates were calculated using census data. Risk factors for PLA were identified using a multivariate analysis. Data was compared to 1999–2003 data, also collected in the CHZ.

Results

There were 136 patients diagnosed with PLA between 2015 and 2017. Incidence rate during this period increased significantly relative to 1999–2003 (3.7 vs 2.3 cases/100,000 population, p < 0.01), however, mortality rates remained similar. The microbiological composition of PLA did not change over this 15-year time period but the number of antimicrobial resistant isolates did increase (8% vs 1%, p = 0.04). The greatest risk factors for PLA relative to general populations included current malignancy, liver-transplant, end-stage renal disease, and cirrhosis. Thirty-day mortality was 7.4% and independent risk factors included polymicrobial bacteremia, absence of abscess drainage, congestive-heart failure, a history of liver disease, and admission bilirubin.

Conclusions

Pyogenic liver abscess is a health concern with rising incidence rate. The increasing prevalence of comorbidities in our population and factors that are associated with risk of PLA suggests this will continue to be an emerging diagnosis of concern. Increasing prevalence of antibiotic resistant organisms compounding unclear optimal treatment regimens is an issue that requires urgent study.

Imaging of calcified hepatic lesions: spectrum of diseases

Hepatic calcifications have been increasingly identified over the past decade due to the widespread use of high-resolution Computed Tomography (CT) imaging. Calcifications can be seen in a vast spectrum of common and uncommon diseases, from benign to malignant, including cystic lesions, solid neoplastic masses, and inflammatory focal lesions. The purpose of this paper is to present an updated review of CT imaging findings of a wide range of calcified hepatic focal lesions, which can help radiologists to narrow the differential diagnosis.

Imaging of abdominal and pelvic infections in the cancer patient

Infections are the most commonly encountered complications in patients with cancer. The classical signs and symptoms of infections are often not present in this patient population, which makes the diagnosis more challenging. Host factors play a major role in the development and prognosis of infections in cancer patients; these can be related to the underlying type of malignancy (solid organ versus hematological), tumor burden, anatomic obstruction, altered integrity of barriers (skin or mucosa), treatment-related factors (from chemotherapy, radiation treatment, surgery, interventional procedures, and/or medical device placement) and the degree of immunosuppression. This article reviews common, as well as less common, imaging manifestations of infections and their potential mimics in the abdomen and pelvis in cancer patients and discusses their differentiating features, with the role of imaging in various organs in the abdomen and pelvis taking into consideration relevant clinical background information and the main risk factors.

Gastrointestinal and Abdominal Tuberculosis

Gastrointestinal (GI) tuberculosis (TB) remains a significant problem worldwide, and may involve the luminal GI tract from oral cavity to perianal area in addition to associated viscera and peritoneum. Although GI TB more commonly affects immunocompromised hosts, it can also occur in immunocompetent people. Diagnosis is difficult because it usually mimics a malignancy or inflammatory bowel disease. A high index of clinical suspicion and appropriate use of combined investigative methods help in early diagnosis, and reduce morbidity and mortality. Anti-TB therapy is the same as for pulmonary disease, and invasive and specialized interventions are reserved for selected complications.

Role of MRI in the Evaluation of Thoracoabdominal Emergencies

Thoracic and abdominal pathology are common in the emergency setting. Although computed tomography is preferred in many clinical situations, magnetic resonance imaging (MRI) and magnetic resonance angiography (MRA) have emerged as powerful techniques that often play a complementary role to computed tomography or may have a primary role in selected patient populations in which radiation is of specific concern or intravenous iodinated contrast is contraindicated. This review will highlight the role of MRI and MRA in the emergent imaging of thoracoabdominal pathology, specifically covering acute aortic pathology (acute aortic syndrome, aortic aneurysm, and aortitis), pulmonary embolism, gastrointestinal conditions such as appendicitis and Crohn disease, pancreatic and hepatobiliary disease (pancreatitis, choledocholithiasis, cholecystitis, and liver abscess), and genitourinary pathology (urolithiasis and pyelonephritis). In each section, we will highlight the specific role for MRI, discuss basic imaging protocols, and illustrate the MRI features of commonly encountered thoracoabdominal pathology.