1979, British Journal of Radiology, 52, 897-899
NOVEMBER 1979
Case reports Polycystic liver and other hepatic masses mimicking gall-bladder disease By M. W. Hedgcock, M.D.,* J . D. Shanser, M.D., R. L. Eisenberg, M.D. Departments of Radiology, University of California School of Medicine and Veterans Administration Hospital, San Francisco, California and D. K. Westmoreland, M.D. Department of Radiology, University of Tennessee College of Medicine, Memphis, Tennessee, USA (Received August 1978 and in revised form March 1979) Hepatic and biliary tract diseases can both present as pain or mass in the right upper quadrant of the abdomen. Occasionally, hepatic masses impress the gall-bladder, simulating gall-bladder disease both symptomatically and radiographically. Ultrasonography and computed tomography (CT) imaging have facilitated the preoperative differentiation between hepatic and biliary tract disease and, further, between cysts (polycystic liver disease) and solid tumours. We wish to report a patient with hepatic masses and review similar reports to illustrate that when filling defects are noted in the gallbladder on the cholecystogram, hepatic disease can then be differentiated from biliary tract disease without the need for laparotomy. CASE REPORT
A 45-year-old hypertensive woman was admitted to our hospital because of a six-month history of an enlarging abdominal mass and a sensation of pressure and fullness. She had no associated pain, jaundice, nausea, vomiting, or change in bowel habits. Physical examination disclosed an enlarged, non-tender liver and discrete, mobile masses 8 to 12 cm in diameter in the mid epigastrium. Laboratory studies revealed no abnormalities. An oral cholecystogram showed two large filling defects in the lateral aspect of the fundus of the gall-bladder (Fig. 1). An upper gastrointestinal series showed a mass impressing the duodenal bulb (Fig. 2). Excretory urography with tomography demonstrated numerous cysts of various sizes within the kidneys and liver (Fig. 3). Technetium 99m sulphur colloid scintiphotos showed an enlarged liver with multiple areas of diminished uptake (Fig. 4). Ultrasonographic examination of the liver (Fig. 5) and kidneys revealed that these areas of diminished uptake were sonolucent with strong through transmission consistent with multiple cysts. The cysts were separate from the gallbladder. The radiographic findings combined with those from ultrasonography and scintigraphy strongly indicated the diagnosis of polycystic liver and kidney disease. The patient was discharged without surgical intervention and has done well. Two years later, oral cholecystography, excretory urography, radionuclide scanning of the liver, and ultrasonography of the liver and kidneys demonstrated no change in findings. •Present address to which requests for reprints should be sent: Department of Radiology, M-396, University of California, San Francisco, California 94143.
FIG. 1. Oral cholecystogram showing round, filling defects in lateral aspect of the gall-bladder.
DISCUSSION
Several types of hepatic masses can cause filling defects in the gall-bladder on the oral cholecystogram (Fisher, 1968). Polycystic disease of the liver has been suspected to cause this effect in five of the cases reported (Fisher, 1968; Joffe and Babenco, 1974). Polycystic disease of the liver is frequently asymptomatic; however, one report (Comfort et al., 1952) of 24 patients with polycystic disease of the liver or kidney, or both, showed that 13 patients had symptoms referable to the liver. Specific symptoms
897
VOL.
52, No. 623 Case reports
for these 13 patients were right upper quadrant mass, pressure or dull abdominal discomfort, needle-like right upper quadrant pain, and colicky abdominal pain (in one case accompanied by chills and fever). At surgery, none of the 13 patients was found to have gall-bladder disease. The similarity of the above symptoms to those of gall-bladder disease is obvious. Moreover, the age
FIG. 2. X-ray film from upper gastrointestinal series shows mass impression on superior aspect of the duodenal bulb and also extrinsic indentation on upper surface of pyloric antrum.
3. Nephrotomogram shows multiple cystic lesions in enlarged kidneys and liver. FIG.
distribution of patients having polycystic disease of the liver is similar to that for patients with gallbladder disease-both often first diagnosed when the patients are between the fifth and sixth decades of life (Sandy, 1965). Other intrahepatic masses that impress the gallbladder are solitary liver cyst, primary hepatoma, haemangioma, metastatic carcinoma (Joffe and Babenco, 1974), and hepar lobatum (due to tertiary syphillis) (Fisher, 1968). In patients with these diseases the presenting symptoms also frequently mimic gall-bladder disease. Fisher (1968) suggests that liver abscesses, liver granulomas, or liver lobulation due to scarring can also deform the gallbladder.
FIG. 4. Right lateral liver scan using technetium-99m sulphur colloid showing enlarged liver with multiple areas of diminished uptake.
FIG. 5. Transverse ultrasonogram of the liver at level of umbilicus + 14 cm shows multiple cystic lesions with characteristic acoustical transmission.
898
1979, British Journal of Radiology, 52, 899—901
NOVEMBER 1979
Case reports
Extrahepatic masses that can impress the gallbladder include the duodenal bulb, distended colon, and peripheral lymph nodes (Fisher, 1968). Although impressions by bowel should not present a diagnostic problem, lymph nodes impressing the gall-bladder could produce radiographic findings that mimic intrinsic gall-bladder disease. In the literature, we found 11 cases in which masses extrinsic to the gall-bladder produced radiographic findings that mimicked gall-bladder disease. The findings on the X-ray films of these reported patients (Comfort et al, 1952; Fisher, 1968; Joffe and Babenco, 1974) consisted primarily of single or multiple filling defects in the gall-bladder on the cholecystogram. Although the filling defects usually changed in appearance with change in patient position, they remained fixed when the gall-bladder was adherent to the liver or intrahepatic in location. In addition to impressions upon the gall-bladder, other findings noted on X-ray films were displacement of the duodenum, stomach, or colon and elevation of the right hemidiaphragm by an enlarged liver (Geist, 1955). As well as extrinsic compression of the gallbladder, the differential diagnosis of filling defects of the type shown in our case noted on cholecystograms includes adenomyomatosis, intramural cyst or granuloma, and neoplasms (Joffe and Babenco, 1974). Although Niemetz et al. suggested in 1949 that there are no radiographic signs characteristic of polycystic disease of the liver, cyst wall calcification has been considered to be highly suggestive of polycystic liver (Comfort et al., 1952). The advent of imaging modalities such as ultrasonography and computed tomography (CT) has recently made possible preoperative diagnosis of polycystic disease of the liver in most cases (Igawa and Miyagishi, 1972; Taylor et al., 1976). Ultrasound and CT body scanning are also extremely accurate in defining the nature of hepatic lesions (Alfidi et ah, 1976) and can
often help differentiate hepatic from gall-bladder disease. In our patient, ultrasonograms demonstrated multiple fluid-filled cysts adjacent to the gallbladder. Further diagnostic evaluation by means of excretory urography disclosed the classic radiographic appearance of polycystic kidney disease. It is particularly noteworthy that renal involvement in patients with polycystic liver disease occurs with only 50% frequency (Sandy, 1965); therefore, the excretory urogram often will not aid in the differential diagnosis. Ultrasound and CT body scanning should be able to obviate the need for laparotomy. Surgical treatment of polycystic disease of the liver is generally unsatisfactory, with cyst puncture offering only temporary relief from the patient's sense of weight or pressure in the abdomen. The diffuse distribution of cysts in the liver makes attempts at radical surgical treatment unfeasible in most instances (Comfort et al., 1952). REFERENCES ALFIDI, R. J., HAAGA, J. R., HAVRILLA, T. R., PEPE, R. G.
and COOK, S. A., 1976. Computed tomography of the liver. American Journal of Roentgenology, 127, 69-74. COMFORT, M. W., GRAY, H. K., DAHLIN, D. C. and
WHITESELL, F. B., Jr., 1952. Polycystic disease of the liver: a study of 24 cases. Gastroenterology, 20, 60-78. FISHER, M. S., 1968. Hepar lobatum and other less exotic causes of gall-bladder deformity. Radiology, 91, 308-309. GEIST, D. C , 1955. Solitary nonparasitic cyst of the liver: review of the literature and report of two patients. Archives of Surgery, 71, 867-880. IGAWA, K. and MIYAGISHI, T., 1972. The use of scintillation
and ultrasonic scanning to disclose polycystic kidneys and liver. Journal of Urology, 108, 685-688. JOFFE, N. and BABENCO, G. O., 1974. Localized deformity of
the gallbladder secondary to hepatic mass lesions. American Journal of Roentgenology, 121, 412-419. NIEMETZ, D., SOKOL, A. and MEISTER, L., 1949. Polycystic
disease of the liver: report of two cases diagnosed by peritoneoscopy. Annals of Internal Medicine, 31, 319-324. SANDY, R. E., 1965. Cholecystography in the presence of polycystic disease of the liver: report of a case and review of the literature. Radiology, 85,895-897. TAYLOR, J. K. W., CARPENTER, D. A., HILL, C. R. and
MCCREADY, V. R., 1976. Gray scale ultrasound imaging: the anatomy and pathology of the liver. Radiology, 119, 415-423.
The ultrasound appearance of subdiaphragmatic rupture of a right lobe liver abscess in a two-year-old child By J. E. Boultbee, F.R.C.R. and D. A. Lloyd, M.Chir.(Cantab), F.R.C.S. Departments of Radiology and Paediatric Surgery, Faculty of Medicine, University of Natal, South Africa (ReceivedMay 1979)
Amoebic liver abscess is a common disease amongst the black population in the coastal region of Natal. All age groups may be affected and if diagnosed
early and treated properly the disease carries a good prognosis (Adams and MacLeod, 1977). We use ultrasound routinely for diagnosis and for accurate 899
NOVEMBER 1979
Case reports Polycystic liver and other hepatic masses mimicking gall-bladder disease By M. W. Hedgcock, M.D.,* J . D. Shanser, M.D., R. L. Eisenberg, M.D. Departments of Radiology, University of California School of Medicine and Veterans Administration Hospital, San Francisco, California and D. K. Westmoreland, M.D. Department of Radiology, University of Tennessee College of Medicine, Memphis, Tennessee, USA (Received August 1978 and in revised form March 1979) Hepatic and biliary tract diseases can both present as pain or mass in the right upper quadrant of the abdomen. Occasionally, hepatic masses impress the gall-bladder, simulating gall-bladder disease both symptomatically and radiographically. Ultrasonography and computed tomography (CT) imaging have facilitated the preoperative differentiation between hepatic and biliary tract disease and, further, between cysts (polycystic liver disease) and solid tumours. We wish to report a patient with hepatic masses and review similar reports to illustrate that when filling defects are noted in the gallbladder on the cholecystogram, hepatic disease can then be differentiated from biliary tract disease without the need for laparotomy. CASE REPORT
A 45-year-old hypertensive woman was admitted to our hospital because of a six-month history of an enlarging abdominal mass and a sensation of pressure and fullness. She had no associated pain, jaundice, nausea, vomiting, or change in bowel habits. Physical examination disclosed an enlarged, non-tender liver and discrete, mobile masses 8 to 12 cm in diameter in the mid epigastrium. Laboratory studies revealed no abnormalities. An oral cholecystogram showed two large filling defects in the lateral aspect of the fundus of the gall-bladder (Fig. 1). An upper gastrointestinal series showed a mass impressing the duodenal bulb (Fig. 2). Excretory urography with tomography demonstrated numerous cysts of various sizes within the kidneys and liver (Fig. 3). Technetium 99m sulphur colloid scintiphotos showed an enlarged liver with multiple areas of diminished uptake (Fig. 4). Ultrasonographic examination of the liver (Fig. 5) and kidneys revealed that these areas of diminished uptake were sonolucent with strong through transmission consistent with multiple cysts. The cysts were separate from the gallbladder. The radiographic findings combined with those from ultrasonography and scintigraphy strongly indicated the diagnosis of polycystic liver and kidney disease. The patient was discharged without surgical intervention and has done well. Two years later, oral cholecystography, excretory urography, radionuclide scanning of the liver, and ultrasonography of the liver and kidneys demonstrated no change in findings. •Present address to which requests for reprints should be sent: Department of Radiology, M-396, University of California, San Francisco, California 94143.
FIG. 1. Oral cholecystogram showing round, filling defects in lateral aspect of the gall-bladder.
DISCUSSION
Several types of hepatic masses can cause filling defects in the gall-bladder on the oral cholecystogram (Fisher, 1968). Polycystic disease of the liver has been suspected to cause this effect in five of the cases reported (Fisher, 1968; Joffe and Babenco, 1974). Polycystic disease of the liver is frequently asymptomatic; however, one report (Comfort et al., 1952) of 24 patients with polycystic disease of the liver or kidney, or both, showed that 13 patients had symptoms referable to the liver. Specific symptoms
897
VOL.
52, No. 623 Case reports
for these 13 patients were right upper quadrant mass, pressure or dull abdominal discomfort, needle-like right upper quadrant pain, and colicky abdominal pain (in one case accompanied by chills and fever). At surgery, none of the 13 patients was found to have gall-bladder disease. The similarity of the above symptoms to those of gall-bladder disease is obvious. Moreover, the age
FIG. 2. X-ray film from upper gastrointestinal series shows mass impression on superior aspect of the duodenal bulb and also extrinsic indentation on upper surface of pyloric antrum.
3. Nephrotomogram shows multiple cystic lesions in enlarged kidneys and liver. FIG.
distribution of patients having polycystic disease of the liver is similar to that for patients with gallbladder disease-both often first diagnosed when the patients are between the fifth and sixth decades of life (Sandy, 1965). Other intrahepatic masses that impress the gallbladder are solitary liver cyst, primary hepatoma, haemangioma, metastatic carcinoma (Joffe and Babenco, 1974), and hepar lobatum (due to tertiary syphillis) (Fisher, 1968). In patients with these diseases the presenting symptoms also frequently mimic gall-bladder disease. Fisher (1968) suggests that liver abscesses, liver granulomas, or liver lobulation due to scarring can also deform the gallbladder.
FIG. 4. Right lateral liver scan using technetium-99m sulphur colloid showing enlarged liver with multiple areas of diminished uptake.
FIG. 5. Transverse ultrasonogram of the liver at level of umbilicus + 14 cm shows multiple cystic lesions with characteristic acoustical transmission.
898
1979, British Journal of Radiology, 52, 899—901
NOVEMBER 1979
Case reports
Extrahepatic masses that can impress the gallbladder include the duodenal bulb, distended colon, and peripheral lymph nodes (Fisher, 1968). Although impressions by bowel should not present a diagnostic problem, lymph nodes impressing the gall-bladder could produce radiographic findings that mimic intrinsic gall-bladder disease. In the literature, we found 11 cases in which masses extrinsic to the gall-bladder produced radiographic findings that mimicked gall-bladder disease. The findings on the X-ray films of these reported patients (Comfort et al, 1952; Fisher, 1968; Joffe and Babenco, 1974) consisted primarily of single or multiple filling defects in the gall-bladder on the cholecystogram. Although the filling defects usually changed in appearance with change in patient position, they remained fixed when the gall-bladder was adherent to the liver or intrahepatic in location. In addition to impressions upon the gall-bladder, other findings noted on X-ray films were displacement of the duodenum, stomach, or colon and elevation of the right hemidiaphragm by an enlarged liver (Geist, 1955). As well as extrinsic compression of the gallbladder, the differential diagnosis of filling defects of the type shown in our case noted on cholecystograms includes adenomyomatosis, intramural cyst or granuloma, and neoplasms (Joffe and Babenco, 1974). Although Niemetz et al. suggested in 1949 that there are no radiographic signs characteristic of polycystic disease of the liver, cyst wall calcification has been considered to be highly suggestive of polycystic liver (Comfort et al., 1952). The advent of imaging modalities such as ultrasonography and computed tomography (CT) has recently made possible preoperative diagnosis of polycystic disease of the liver in most cases (Igawa and Miyagishi, 1972; Taylor et al., 1976). Ultrasound and CT body scanning are also extremely accurate in defining the nature of hepatic lesions (Alfidi et ah, 1976) and can
often help differentiate hepatic from gall-bladder disease. In our patient, ultrasonograms demonstrated multiple fluid-filled cysts adjacent to the gallbladder. Further diagnostic evaluation by means of excretory urography disclosed the classic radiographic appearance of polycystic kidney disease. It is particularly noteworthy that renal involvement in patients with polycystic liver disease occurs with only 50% frequency (Sandy, 1965); therefore, the excretory urogram often will not aid in the differential diagnosis. Ultrasound and CT body scanning should be able to obviate the need for laparotomy. Surgical treatment of polycystic disease of the liver is generally unsatisfactory, with cyst puncture offering only temporary relief from the patient's sense of weight or pressure in the abdomen. The diffuse distribution of cysts in the liver makes attempts at radical surgical treatment unfeasible in most instances (Comfort et al., 1952). REFERENCES ALFIDI, R. J., HAAGA, J. R., HAVRILLA, T. R., PEPE, R. G.
and COOK, S. A., 1976. Computed tomography of the liver. American Journal of Roentgenology, 127, 69-74. COMFORT, M. W., GRAY, H. K., DAHLIN, D. C. and
WHITESELL, F. B., Jr., 1952. Polycystic disease of the liver: a study of 24 cases. Gastroenterology, 20, 60-78. FISHER, M. S., 1968. Hepar lobatum and other less exotic causes of gall-bladder deformity. Radiology, 91, 308-309. GEIST, D. C , 1955. Solitary nonparasitic cyst of the liver: review of the literature and report of two patients. Archives of Surgery, 71, 867-880. IGAWA, K. and MIYAGISHI, T., 1972. The use of scintillation
and ultrasonic scanning to disclose polycystic kidneys and liver. Journal of Urology, 108, 685-688. JOFFE, N. and BABENCO, G. O., 1974. Localized deformity of
the gallbladder secondary to hepatic mass lesions. American Journal of Roentgenology, 121, 412-419. NIEMETZ, D., SOKOL, A. and MEISTER, L., 1949. Polycystic
disease of the liver: report of two cases diagnosed by peritoneoscopy. Annals of Internal Medicine, 31, 319-324. SANDY, R. E., 1965. Cholecystography in the presence of polycystic disease of the liver: report of a case and review of the literature. Radiology, 85,895-897. TAYLOR, J. K. W., CARPENTER, D. A., HILL, C. R. and
MCCREADY, V. R., 1976. Gray scale ultrasound imaging: the anatomy and pathology of the liver. Radiology, 119, 415-423.
The ultrasound appearance of subdiaphragmatic rupture of a right lobe liver abscess in a two-year-old child By J. E. Boultbee, F.R.C.R. and D. A. Lloyd, M.Chir.(Cantab), F.R.C.S. Departments of Radiology and Paediatric Surgery, Faculty of Medicine, University of Natal, South Africa (ReceivedMay 1979)
Amoebic liver abscess is a common disease amongst the black population in the coastal region of Natal. All age groups may be affected and if diagnosed
early and treated properly the disease carries a good prognosis (Adams and MacLeod, 1977). We use ultrasound routinely for diagnosis and for accurate 899
