Liver Red Flags

Eduardo Davino Chiovatto¹
Alessandra Rodrigues Silva Chiovatto¹
Marcelo Violi Schelini¹
Fernando Linhares Pereira^{1, 2}
Julia Diva Zavaris^{1, 2}
Maria Cristina Chammas^{1, 2}
Wagner Iared^{1, 3}

1.) Ultrasonography Improvement and Research Center Prof. Dr. Giovanni Guido Cerri, DASA, São Paulo, Brazil.

2.) Institue of Radiology, Hospital das Clinicas School of Medicine, University of São Paulo, São Paulo, Brazil

3.) Department of Medicine – Federal University of São Paulo, São Paulo, Brazil.

Clinical History:

A 68-year-old female from the countryside of São Paulo was referred to our clinic for a routine ultrasound examination. She had diabetes and arterial hypertension and no history of hepatitis, alcoholism or AIDS.

Question: In this case, the main signs and probable diagnosis are:

1. Low velocities in portal vein and notched liver surface - Hepatitis
2. Splenomegaly with siderotic nodules and caudate lobe hypertrophy – Alcohol Cirrhosis
3. Thick and echogenic bands surrounding portal vessels and gallbladder – Schistosomiasis (hepatosplenic form)
4. Collateral vessel and heterogeneity of the liver parenchyma – Early-stage schistosomiasis

Correct

CORRECT ANSWER EXPLAINED BELOW

Correct answer is:

Thick and echogenic bands surrounding the portal vessels and gallbladder. – Schistosomiasis (hepatosplenic form)

Explanation:

Schistosomiasis is an important health problem in underdeveloped countries, especially in South America. The case represents a hepatosplenic form of this disease. The main findings in this presentation are thick and echogenic bands around the portal vessels and the gallbladder. Splenomegaly is highly prevalent in these patients, often with siderotic nodules. The rate of blood flow in the portal vein is usually normal (>16 cm/s) in the early stages of the disease.

In cirrhosis the main signs are nodulated liver surface, parenchymal disorganization, caudate lobe hypertrophy and portal hypertension with low blood flow speeds in the portal vein, typically <15 cm/s.^1,2,3

Take home message:

Although ultrasound findings must be associated with epidemiologic information for best accuracy, in a liver marked by periportal thickening, especially if associated with pronounced splenomegaly, schistosomiasis must be remembered in the differential diagnoses of liver diseases. Special attention must be taken to the thick and echogenic bands surrounding the portal vessels and the gallbladder.

References

Azevedo, LM; Queroz LC; Santo, MCCE; Chammas, MC. Aspectos ultrassonográficos e hemodinâmicos da esquitossomose mansônica: avaliação pela ultrassonografia Doppler em áreas endêmicas. Radiologia Brasileira, vol.43 nº2-Mar/Abr 2010
Hatz C, Jenkins JM, Ali QM, Abdel- Wahab MF, Cerri GG, Tanner M. A review of the literature on the use of ultrasonography in schistosomiasis with special reference to its use in field studies. 2. Schistosoma mansoni. Acta Trop 1992;51:15¾28CH, Dickman K, Tisch DJ. Reassessment of the cost of chronic helmintic infection: a meta-analysis of disability-related outcomes in endemic schistosomiasis. Lancet 2005; 365:1561.
Meurs L, Mbow M, Vereecken K, et al. Epidemiology of mixed Schistosoma mansoni and Schistosoma haematobium infections in northern Senegal. Int J Parasitol 2012; 42:305.

Incorrect

CORRECT ANSWER EXPLAINED BELOW

Correct answer is:

Thick and echogenic bands surrounding the portal vessels and gallbladder. – Schistosomiasis (hepatosplenic form)

Explanation:

Schistosomiasis is an important health problem in underdeveloped countries, especially in South America. The case represents a hepatosplenic form of this disease. The main findings in this presentation are thick and echogenic bands around the portal vessels and the gallbladder. Splenomegaly is highly prevalent in these patients, often with siderotic nodules. The rate of blood flow in the portal vein is usually normal (>16 cm/s) in the early stages of the disease.

In cirrhosis the main signs are nodulated liver surface, parenchymal disorganization, caudate lobe hypertrophy and portal hypertension with low blood flow speeds in the portal vein, typically <15 cm/s.^1,2,3

Take home message:

Although ultrasound findings must be associated with epidemiologic information for best accuracy, in a liver marked by periportal thickening, especially if associated with pronounced splenomegaly, schistosomiasis must be remembered in the differential diagnoses of liver diseases. Special attention must be taken to the thick and echogenic bands surrounding the portal vessels and the gallbladder.

References

Azevedo, LM; Queroz LC; Santo, MCCE; Chammas, MC. Aspectos ultrassonográficos e hemodinâmicos da esquitossomose mansônica: avaliação pela ultrassonografia Doppler em áreas endêmicas. Radiologia Brasileira, vol.43 nº2-Mar/Abr 2010
Hatz C, Jenkins JM, Ali QM, Abdel- Wahab MF, Cerri GG, Tanner M. A review of the literature on the use of ultrasonography in schistosomiasis with special reference to its use in field studies. 2. Schistosoma mansoni. Acta Trop 1992;51:15¾28CH, Dickman K, Tisch DJ. Reassessment of the cost of chronic helmintic infection: a meta-analysis of disability-related outcomes in endemic schistosomiasis. Lancet 2005; 365:1561.
Meurs L, Mbow M, Vereecken K, et al. Epidemiology of mixed Schistosoma mansoni and Schistosoma haematobium infections in northern Senegal. Int J Parasitol 2012; 42:305.

Case of the Month June 2020- Liver Red Flags

Liver Red Flags

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1. Question

Question: In this case, the main signs and probable diagnosis are:

Correct answer is:

Explanation:

Take home message:

References

Correct answer is:

Explanation:

Take home message:

References

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