Correct answer to Q1 is: Dilated bowel loops

Correct answer to Q2 is: Acute retrocecal appendicitis and a mesenteric node

That is incorrect.

There is a small focal liver lesion,  a 1.6 x 1.8 x 1.3 cms slightly hypoechoic with an echogenic center which was demonstrated by colour ultrasound to be a vascular component, central scar, it’s not an injury since the patient had no trauma

Correct answer to Q4 is: Nodular focal hyperplasia

Discussion

The ultrasound study confirmed the clinical suspicion of appendicitis, although initially difficult to assess, this led to a thorough examination of the patient. While looking for another cause of the pain, a focal liver lesion was found. We identified, in the right lobe of the liver, a 1.6 x 1.8 x 1.3 cms a hypoechoic lesion with a central scar and dominant vascular component. This is considered a characteristic image of Focal nodular hyperplasia (FNH). FNH is the most common benign focal liver lesion in women aged between 25 and 50 years, often discovered incidentally in asymptomatic patients. In general, there is no relation between FNH with the intake of exogenous estrogens. These lesions from a histopathological point of view demonstrate proliferation of hyperplastic hepatocytes that surround a central scar, typically it is a solitary lesion, due to damage to a portal path which causes the formation of arteriovenous shunts. The recommendation in asymptomatic patients with lesions such as the case presented, is control with images every 6 months for a period of three years

Conclusion

It is important not to limit ourselves exclusively to the evaluation of FID when we perform a study for suspected appendicitis, since additional examination may provide important findings for patient follow-up and control. In the case presented despite the fact of been younger than the average age of presentation, the finding of an hypoechoic focal liver lesion with a central scar and dominant vascular component, led to the diagnosis of nodular focal hyperplasia. It was decided not to expose the patient to another study such as tomography, especially considering it is a very small lesion in an asymptomatic patient with no abnormal findings in her blood samples. Follow-up studies every 6 month was suggested.

Conflicts of interest

“The authors declare no conflict of interest.”

References

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