A young man with progressive jaundice and abdominal distension

Budd-Chiari syndrome (BCS) is a rare, life-threatening disease caused by obstruction of hepatic venous outflow. Common presentations are right upper quadrant pain, ascites, and hepatomegaly. A diagnosis of Budd-Chiari syndrome should be suspected when liver disease occurs in a patient with known risk factors for hypercoagulable state. We report a 22-years old transgender man presented with jaundice, marked ascites and hepatomegaly. Imaging studies showed complete thrombosis of all hepatic veins. Finally, he was diagnosed with Budd-Chiari syndrome with antiphospholipid syndrome. Figure 1 ภาพ CT upper abdomen แสดงให้เห็น marked ascites with heterogeneous liver enhancement, complete obliteration of all hepatic, caudate lobe hypertrophy, small intrahepatic venous collateral และ small arterial enhancing nodules

Systemic therapy in unresectable HCC

For decade, systemic treatments in advanced stage hepatocellular carcinoma (HCC), except sorafenib, were not very effective even though there were tremendous effort in developing new therapy. Until last 2 years, Nivolumab, the new immune check point inhibitor, has shown promising activity in phase I/II study and have been approved by USFDA to treat patients in first and second line due to their benefits on overall survival and the adequate safety profile. Not only nivolumab, but also lenvatinib; multikinase inhibitor, is approved in advanced HCC due to a positive impact on the overall survival. Still sorafenib is the drug that have been used to treat unresectable HCC for over 10 years with best benefits on overall survival and the adequate safety profile in selected patients. Therefore, this article was to reveal all the data about systemic therapies that were used in advanced stage HCC include indication, dosage, patient and drug’s profile and safety. The strategy to precisely select treatment for advanced or unresectable HCC is now more challenging than ever before because there were many promising drugs available in the market. Thus, as a clinician, we are responsible to gather all the important information from patients to choose the best treatment option not only to prolong survival but to achieve complete response in these metastasis liver cancers. Figure 1 ยาที่ได้รับการรับรองจากองค์การอาหารและยาของประเทศสหรัฐอเมริกาในการรักษามะเร็งตับระยะลุกลาม มะเร็งตับระยะ B หมายถึง มะเร็งตับระยะ Intermediated แบ่งตาม Barcelona Clinic Liver Cancer มะเร็งตับระยะ C หมายถึง มะเร็งตับระยะ Advanced แบ่งตาม Barcelona Clinic Liver Cancer

Basic knowledge for hepatic MRI interpretation

Nowadays, Magnetic resonance imaging (MRI) has an important role for diagnosis of liver lesions due to excellent tissue characterization, radiation-free technique and continuous development of MRI technology, causing an increased use of MRI. This article focuses on basic knowledge of MRI liver interpretation for non-radiologist. The basic techniques including T1-weighted and T2-weighted sequences as well as additional techniques such as 2D dual GRE in-phase and opposed-phase, fat suppression or heavily T2-weighted sequences were introduced. Types of MR contrast agents for liver including extracellular and hepatocyte-specific agents were also described. Figure 1 เป็นภาพ MRI ของตับเทคนิค T1W โดยอวัยวะส่วนใหญ่ที่ปรากฏในภาพจะให้ลักษณะ signal intensity ไปในทางhypointense ซึ่งจะเห็นว่าม้าม (spleen=S) ดำกว่าตับ (liver=L) และตับจะดำกว่าตับอ่อน (pancreas=P) โดยลูกศรสีดำชี้ให้เห็น signal intensity ของน้ำไขสันหลังที่เป็นลักษณะ hypointense

Fascioliasis

Fascioliasis is infection by liver flukes, Fasciola spp. The two species that infect humans are Fasciola hepatica and Fasciola gigantica. Other herbivorous animals such as cattle, goats, water buffalo, horses, camels, hogs, rabbits, and deer can be infected with Fasciola spp. Humans acquire Fasciola after ingestion of food and water that are contaminated with Fasciola metacercaria, especially aquatic plants. Fascioliasis is usually mild disease in human. Clinical manifestrations are related with the the phases of infection. In migratory phase, symptoms may occur when metacercariae excyst in the duodenum and young liver flukes migrate through the intestinal wall to the liver capsule and hepatic parenchyma before reaching the bile ducts. Clinical symptoms include abdominal pain in the right hypochondrium, dyspepsia and anorexia, nausea, vomiting, and hepatomegaly. Systemic manifestration such as urticaria and eosinophilia are also common presentation. After Fasciola reside in the biliary tract, most of cases are asymptomatic. Biliary track obstruction can accidentally occur and might lead to cholangitis. Triclabendazole 10 mg/kg as a single dose is the current drug of choice for fascioliasis treatment and triclabendazole two doses of 10 mg/kg for 1 day is effective in severe or persistent infections, with cure rates of 79% and 92%, respectively. Currently, there is no vaccine for prevent Fasciola infection. Proper cooking or cleaning food especially aquatic plants before consumption will prevent accidental Fasciola infection. Adequate mass treatment among infected animals in endemic areas and proper sanitary in the livestock farm are important for disease control. Figure 1 ภาพถ่ายตัวเต็มวัยพยาธิ Fasciola hepatica (Linnaeus, 1758) (A) และ Fasciola gigantica (Cobbold, 1855) (B)(ได้รับการอนุเคราะห์ภาพจาก รศ.ดร.อุรุษา แทนขำ ภาควิชาปรสิตหนอนพยาธิ คณะเวชศาสตร์เขตร้อน มหาวิทยาลัยมหิดล)

A man with history of heavy alcoholic drinking

A 33-year-old Thai man presented with fever and jaundice for 10 days. He had history of significant alcohol intake. Physical examination revealed tender hepatomegaly and signs of chronic liver stigmata. Laboratory results showed: TB 17.5 mg/dL; DB 13.1 mg/dL; AST 230 IU/L; ALT 77 IU/L; ALP 332 IU/L; albumin 2.5 g/dL; globulin 3.9 g/dL; PT 13.4 sec. Serum immunologic test were negative for HAV, HBV, HCV and HEV. The histological result from liver biopsy was compatible with alcoholic steatohepatitis. Maddrey’s discriminant function was 79. Prednisolone 40 mg/day was prescribed. The clinical and liver function tests gradually improved after treatment. Figure 1 พยาธิสภาพของชิ้นเนื้อตับ (A) ย้อม H&E (20x) พบ Macrovesicular steatosis, Ballooning hepatocyte & Mallory-Denk bodies (วงกลมสีแดง), Lobular inflammation with neutrophilic infiltrate (วงกลมสีดำ), Canalicular cholestasis (ลูกศร) (B) ย้อม H&E (40x) พบ Ballooning hepatocytes และ Mallory-Denk bodies (ลูกศร) (C) ย้อม Masson’s trichrome พบ Fibrosis stage 4

A young adult with biliary atresia and liver decompensation

Biliary atresia is a progressive fibro-obliterative disease of the bile duct, commonly diagnosed within a few months of life. After hepatoportoenterostomy was successfully performed, about one fourth of biliary atresia patients have grown up to the age of twenty with their native liver. However, progression to liver cirrhosis, development of portal hypertension, or cholangitis are the major problems of adult with biliary atresia. Monitoring of these complications and listing for liver transplantation whenever indicated are the key when caring adult with biliary atresia. Figure 1 แสดง CT abdomen พบว่ามีตับโต และมีลักษณะของตับแข็งและ ภาวะความดันของระบบหลอดเลือด portal สูงขึ้น (collateral vessels, splenomegaly, ascites) พบการขยายตัวของท่อน้ำดีในตับ (multifocal dilated ducts and peribiliary cysts along bilateral intrahepatic ducts) และต่อมน้ำเหลืองโตในช่องท้อง (mesenteric, gastrohepatic, hepatoduodenal, aortocaval, para aortic, right anterior diaphragmatic, lower paraesophageal lymph node ขนาดสูงสุด 1.8 ซม.)

Mass-forming cholangiocarcinoma

Cholangiocarcinoma is the second most common primary liver cancers. It is arising from epithelial cells of the biliary tract. It has been categorized to intrahepatic and extrahepatic. The Intrahepatic orperipheral cholangiocarcinoma can be presented as mass-forming, periductal infiltrating and intraductal growth. Many patients of mass-forming cholangiocarcinoma have symptoms such as abdominal pain about 85% but some patients don’t have any symptoms. This is the difficult cancer to diagnose. While patients were having any symptom, the disease was an advanced stage (unresectable). The diagnostic tools for assess this disease are imaging modalities include ultrasound (US), computed tomography (CT) with contrast, magnetic resonance imaging (MRI) with contrast. However, the goal standard for confirm diagnosis is tissue pathology. This article showed a case presentation and reviewed the imaging appearance of mass-forming cholangiocarcinoma. Figure 1 Axial non-contrast (A), axial contrast enhanced in arterial phase (B), axial contrast enhanced in portal venous phase (C) and axial contrast enhanced in 5-minute delay phase (D) CT scans show a large ill-defined hypodense mass at hepatic segment 7/8, about 7.0x7.0x5.0 cm in APxLxH diameter, which has poor enhancement on arterial phase with gradual progressive enhancement on portal venous and 5-minute delay phase. Coronal contrast enhanced in portal venous phase CT scan (E) shows mass confined in peripheral area of right hepatic lobe with hepatic vein abutment.

A rare cause of upper gastrointestinal bleeding in pregnancy

A 29-year-old 11-week pregnant multigravida woman without previous medical history presentedwith sudden onset of hematemesis. This case illustrates the occurrence of a rare complication (rupture of pseudoaneurysm of right hepatic artery inside the biliary system), appearing as upper gastrointestinal bleeding in a pregnant woman. The cause of the rupture is presumably pregnancy-related. We would like to emphasize the presence of pseudoaneurysm of the hepatic artery as a rare cause of gastrointestinal bleeding in pregnancy. Figure 1 and 2 CTA showed a lobulated contour of saccular aneurysmal dilatation at proximal right hepatic artery, measured about 3.5x3.2x1.6 cm in size and 2.6 mm in neck width; pseudoaneurysm is likely. There is perianeurysmal heterogeneously hyperdense non-enhancing lesion which shows flip-flop phenomenon, measured about 5.5x6.1x5.5 cm in size; Partially thrombosed pseudoaneurysm at proximal right hepatic artery is likely. This lesion causes stretching of the common hepatic artery and portal vein. Hyperdenselesion with flip-flop phenomenon is also seen within dilated bilateral IHD, CHD, CBD and gallbladder; Contrast extravasation into CHD, CBD, 1st, 2nd, 3rd, 4th part of duodenum and jejunum is detected in portovenous phase. hemobilia is suggested.

Typical features of liver Histology in autoimmune hepatitish

Autoimmune hepatitis is a chronic progressive liver disease which may present as acute hepatitis, chronic hepatitis or even cirrhosis. We report a case of 67-year-old female with diabetic mellitus and hyperlipidemia present with progressive fatigue for one year. Her liver function tests showed hepatocellular injury pattern, elevated serum IgG level and positive ANA 1:320 in homogeneous pattern. Her abdominal ultrasound revealed normal liver parenchyma and no bile duct dilatation. The liver biopsy showed interface hepatitis, lymphoplasmacytic infiltration, bridging necrosis, emperipolesis and hepatic rosettes. The diagnosis autoimmune hepatitis was made according to The Simplified Diagnosis Criteria and The Revised Original Scoring System of the International Autoimmune Hepatitis Group. Her clinical and laboratory were improved after received prednisolone and azathioprine. Figure 1 พยาธิสภาพของชิ้นเนื้อตับย้อมด้วย hematoxylin และ eosin (H&E) รูป A และ B: Interface hepatitis (ลูกศรแดง), Cluster of plasma cells infiltration (หัวลูกศรดำ) รูป C: Hepatic rosette formation (*),Emperipolesis (หัวลูกศรดำ)

Ultrasound-guided liver biopsy and drainage

Despite the presence of non-invasive alternatives, liver biopsy remains the indispensable standard for the diagnosis of many liver diseases, and also provides information for prognostic evaluation and clinical therapeutic decision. Ultrasound guidance has become standard practice for percutaneous liver biopsy and also other percutaneous biliary interventions. Ultrasound offers a number of advantages including its real-timed guidance, lack of radiation exposure, inexpensiveness and the ability to perform at the bedside. In this review, I discuss the indications, contraindications, equipment and procedure, possible complications and post-procedural care for the ultrasound-guided hepatic procedures including percutaneous liver biopsy, percutaneous transhepatic biliary drainage, percutaneous cholecystostomy, percutaneous catheter drainage and needle aspiration. Figure 1 การใช้คลื่นเสี่ยงความถี่สูงนำทางเข็มระหว่างการเจาะชิ้นเนื้อตับ