Case Study

Duodenal mass with post hepatic obstruction in a 7 year old FS SharPei

A 7-year-old SF Shar Pei was presented for evaluation of vomiting for 2 days, inappetence, and icterus. CBC was within normal limits. Abnormalities on serum biochemistry were elevated ALT (2067) an ALP activity (977), and total bilirubin. Coagulation panel showed prolonged PTT (71).

DX

Duodenal mass with posthepatic obstruction. Possible early infiltrative disease within the liver.

Image Interpretation

The gastroesophageal inlet in this patient was thickened with hypertrophied muscularis. The upper duodenum in this patient revealed focal thickening with loss of mural detail. The wall thickness measured 2 cm occupying extension of approximately 5-7 cm. Regional lymph node also mildly enlarged measuring 1.5 cm.

Reactive mesentery was noted in the region of the pancreas.

The liver was hypoechoic, mildly irregular. This may be normal for this patient; however, given the bilirubin elevation, early infiltrative disease could not be ruled out. Ultrasound guided FNA was performed without complication. The gallbladder was unremarkable. The cystic duct and common bile duct were mildly dilated the upper limits of normal 0.5 cm. Likely some level of posthepatic obstruction owing to the duodenal pathology. The common bile duct was followed to the level of the duodenal papilla where persistent 0.5-0.8 cm dilation was noted with posthepatic obstruction from the duodenum.

Outcome

Recommend assessment of the FNA of the intestinal mass and liver to assess for micrometastasis in the liver. The hope is that Chemoreduction would be warranted. This is a difficult area to perform resection anastomosis given the pancreatic presentation. Chemoreduction would likely be the best option in this patient if this is round cell neoplasia. Differentials include round cell neoplasia such as lymphoma versus carcinoma.

Clinical Differential Diagnosis

Liver – acute hepatitis (viral, bacterial, toxins), infiltrative neoplasia (lymphoma, mast cell, histiocytosis)
Leptospirosis
Gall bladder – cholecystitis, mucocele
Pancreas – pancreatitis, neoplasia, abscessation