ELECTRONIC CLINICAL CHALLENGES AND IMAGES IN GI A Liver Mass Found After Subtotal Gastrectomy Jieun Koh, Chansik An, and Yong Eun Chung Department of Radiology, Yonsei University, College of Medicine, Seoul, Korea

Question: A 37-yearold woman underwent routine postoperative follow-up imaging study. Two months prior, she had undergone radical subtotal gastrectomy for advanced gastric cancer and a hysterectomy with bilateral salpingooophorectomy for Krukenberg tumor from gastric cancer. After surgery, she had no particular symptoms or abnormal findings on physical examination. Preoperative serum carcinoembryonic antigen (CEA) was 0.84 ng/mL (normal range, 0-5), CA 72-4 was 19.26 U/mL (normal range, 0-8.2), and CA 19-9 was 94.2 U/mL (normal range, 0-37). Postoperative serum CEA was 1.38 ng/mL, CA 72-4 was 40.35 U/mL, and CA 19-9 was 262.0 U/mL. Absent on preoperative CT (Figure A), a 2-cm lowattenuation lesion was visible at the left lateral segment of the liver on postoperative CT (Figure B). What is the most likely diagnosis? See the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI.

Conflicts of interest The authors disclose no conflicts. © 2015 by the AGA Institute 0016-5085/$36.00 http://dx.doi.org/10.1053/j.gastro.2014.10.060

Gastroenterology 2015;148:e5–e6

ELECTRONIC CLINICAL CHALLENGES AND IMAGES IN GI Answer to Image 3: Aberrant Right Gastric Vein

Subsequent MRI demonstrated marked signal drop on out-phase imaging (Figure C) compared with in-phase imaging (Figure D), on T1-gradient chemical shift sequence, suggesting that this lesion was actually a focal fat deposition. We were able to confirm that the aberrant right gastric vein supplied the left medial segment posterior area of the liver on preoperative CT (Figure E). In fact, focal fat depositions at the left medial segment posterior area are often found to be related to an aberrant right gastric vein.1 The incidence of aberrant right gastric vein has been reported variable from 6% to 14%.1 Instances such as this appear late after gastrectomy, which was performed in our case, because aberrant right gastric veins are ligated during surgery, if present.2 Relative ischemic change at this area after surgery, as well as insulin-rich blood from the pancreas head, which cannot be diluted with blood from the stomach, may cause focal fat deposition at this area.3 Accordingly, assessment of the clinical situation, location of the focal fat deposition, direct visualization of an aberrant right gastric vein on preoperative images, and additional chemical shift sequence MR may aid differentiating focal fat deposition from metastasis.2 On the follow-up image studies, focal fat depositions may either resolve or persist.3

References 1. 2. 3.

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Matsui O, Takahashi S, Kadoya M, et al. Pseudolesion in segment IV of the liver at CT during arterial portography: correlation with aberrant gastric venous drainage. Radiology 1994;193:31–35. Sohn B, Lim JS, Hyung WJ, et al. Focal fat deposition developed in the segment IV of the liver following gastrectomy mimicking a hepatic metastasis: two case reports. J Korean Soc Radiol 2012;67:257–261. Yoshimitsu K, Irie H, Kakihara D, et al. Postgastrectomy development or accentuation of focal fatty change in segment IV of the liver: correlation with the presence of aberrant venous branches of the parabiliary venous plexus. J Clin Gastroenterol 2007;41:507–512.

A liver mass found after subtotal gastrectomy.

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