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Special Feature
March 16, 2009

Image of the Month—Quiz Case

Author Affiliations

Author Affiliations:Departments of Surgery (Drs Jain and Pawlik), Radiology (Dr Smith), and Cardiovascular and Interventional Radiology (Dr Geschwind), Johns Hopkins School of Medicine, Baltimore, Maryland.




Copyright 2009 American Medical Association. All Rights Reserved. Applicable FARS/DFARS Restrictions Apply to Government Use.2009

Arch Surg. 2009;144(3):285-286. doi:10.1001/archsurg.2008.578-a

An 85-year-old man with a medical history of hypertension, coronary artery disease, diabetes, chronic renal insufficiency, and alcohol abuse presented with a chief complaint of heartburn and back pain. Right upper quadrant ultrasonography was performed to evaluate for gallstones, but instead it revealed a mass in the left lobe of the liver abutting the stomach. Magnetic resonance imaging of the abdomen (Figure 1) revealed a large (7.5-cm) mass in the left lateral section of the liver, which was confirmed to be hepatocellular carcinoma (HCC) by ultrasonography-guided biopsy. The patient was considered a poor surgical candidate owing to significant medical comorbidities. He was therefore referred for hepatic transarterial chemoembolization (TACE) of the tumor. There was a good response to TACE therapy, with near-complete necrosis of the tumor. The patient tolerated the procedure and initially did well. Approximately 6 weeks following TACE, the patient experienced recurrence of significant abdominal discomfort, nausea, fever, and malaise. He was admitted to another hospital, where he received fluid resuscitation and a course of intravenous antibiotics. Upper endoscopy revealed a large ulcer in the distal stomach. Ultimately, the patient's symptoms improved, and he was discharged home and scheduled for follow-up in our surgical clinic. One week later in our clinic, the patient still complained of intermittent abdominal discomfort and heartburn, but was otherwise well. Physical examination and laboratory examination results were unremarkable. Another abdominal computed tomographic scan was ordered because of the unusual findings on endoscopy (Figure 2).

Figure 1.
Image not available

Magnetic resonance imaging of the abdomen showing a 7.5-cm hepatocellular carcinoma in the left lateral section of the liver.

Figure 2.
Image not available

Computed tomography of the abdomen in a patient with hepatocellular carcinoma.

What Is the Diagnosis?

A. Second primary gastric cancer

B. Perforated gastric ulcer

C. Gastrohepatic fistula

D. Progression of the HCC