– 10 year old FS Golden Retriever w history of diarrhea, possible abdominal discomfort, ADR
– biochem and CBC normal
– survey rads show hepatomegaly
– liver on ultrasound is enlarged, hyperechoic with multiple ill-defined hypoechoic nodules and a few hyperechoic nodules
– rest of scan normal except for slightly small adrenal glands (pole diameters approx 4mm)
– 10 year old FS Golden Retriever w history of diarrhea, possible abdominal discomfort, ADR
– biochem and CBC normal
– survey rads show hepatomegaly
– liver on ultrasound is enlarged, hyperechoic with multiple ill-defined hypoechoic nodules and a few hyperechoic nodules
– rest of scan normal except for slightly small adrenal glands (pole diameters approx 4mm)
I have recommended an ultrasound-guided liver core biopsy (ddx steroid or other vacuolar hepatopathy, benign hyperplasia, CAH, neoplasia (lymphoma, mast cell, hepatocellular carcinioma). I am surprised that the liver enzymes are normal despite such dramatic changes in the liver. Would this lean toward a more benign process?
Comments
Good post JP.
Liver nodules
Good post JP.
Liver nodules and active liver disease and enzyme elevations are 3 separate issues. These nodules in your case are likely nodular hyperplasia or lipogranulomas with minimal potential for hepcell carcinoma or siimilar. My non published approach on this involves the curvilinear theory in that curvilinear patterns respected are tendency toward normalcy whereas when these patterns are disrupted then pathology is in act and the further away form curvilinear the higher the chance of neoplasia and surely the need for sampling.
The abdominal discomfort may be from a combo of hepatomegaly and food overload as he runs out of room int he vcranial abdomen if bulking up on a dry meal with expansion. This thoery fits if the tense abdomen is post prandial but stomach empty on your scan. Also look for referred T-L pain causing abdominal tension… he looks like a body score of 4 or 5 based on that fal fat in your image set… common BS for disc disease:)
If you look closed at the portal veins and curvilinear infrastructure within the nodules whether hyper or hypoechoic you will see that the lines remain straight (arrows) and are not deviated or destroyed. Then look at this hepcell carcinoma case from the basic search
http://sonopath.com/members/case-studies/cases/liver-mass-13-year-old-fs-lhasa-apso-dog
you will see that multiple regions within the mass lose structural curvilinear detail that necessitates sampling or removal. In this case the mass was resectable so removal is the recomendation despite the pathology.
abscesses and necrosis lose curvilinear detail too so lack of curvilinear patterns is NOT=neoplasia in any organ whether liver, pancreas, GI, bladder, adrenal or kidney ..but it means it needs further investigation, sampling, removal and follow-up. If you follow this rule then you can apply it to nearly every presentation in clinical sonography and enhance your gut feeling especially when giving the benefit of the doubt for the patient and to the owner when you aren’t allowed to put a needle in it or cut it out.
These nodules in your case deserve an fna to define (Bx best but if not clinical may be overkill in the big piucture) because they are siognificantly present and we want to be sure nothing more but stick any area where you can’t see the curvilinear detail. That’s where badness lives.
Re liver enzymes: check out my post form a few months ago that I searched out on the forum search box to the left here serach word “enzymes”.
https://sonopath.com/forum/evaluating-benign-liver-coarse-liver-lumped-liver-grandma-liver-enzyme-chase-what-do-they-have
LEs are all over the map in variable pathology.. to me elevated LEs are just a reason to do a sonogram unless Bili GGT and blasting ALT AST are in play which means a hot parenchymal process or if DSAP is driving high rapidly which means an active congestive process. Low albumin and BUN are key parameters too.
Good post JP.
Liver nodules
Good post JP.
Liver nodules and active liver disease and enzyme elevations are 3 separate issues. These nodules in your case are likely nodular hyperplasia or lipogranulomas with minimal potential for hepcell carcinoma or siimilar. My non published approach on this involves the curvilinear theory in that curvilinear patterns respected are tendency toward normalcy whereas when these patterns are disrupted then pathology is in act and the further away form curvilinear the higher the chance of neoplasia and surely the need for sampling.
The abdominal discomfort may be from a combo of hepatomegaly and food overload as he runs out of room int he vcranial abdomen if bulking up on a dry meal with expansion. This thoery fits if the tense abdomen is post prandial but stomach empty on your scan. Also look for referred T-L pain causing abdominal tension… he looks like a body score of 4 or 5 based on that fal fat in your image set… common BS for disc disease:)
If you look closed at the portal veins and curvilinear infrastructure within the nodules whether hyper or hypoechoic you will see that the lines remain straight (arrows) and are not deviated or destroyed. Then look at this hepcell carcinoma case from the basic search
http://sonopath.com/members/case-studies/cases/liver-mass-13-year-old-fs-lhasa-apso-dog
you will see that multiple regions within the mass lose structural curvilinear detail that necessitates sampling or removal. In this case the mass was resectable so removal is the recomendation despite the pathology.
abscesses and necrosis lose curvilinear detail too so lack of curvilinear patterns is NOT=neoplasia in any organ whether liver, pancreas, GI, bladder, adrenal or kidney ..but it means it needs further investigation, sampling, removal and follow-up. If you follow this rule then you can apply it to nearly every presentation in clinical sonography and enhance your gut feeling especially when giving the benefit of the doubt for the patient and to the owner when you aren’t allowed to put a needle in it or cut it out.
These nodules in your case deserve an fna to define (Bx best but if not clinical may be overkill in the big piucture) because they are siognificantly present and we want to be sure nothing more but stick any area where you can’t see the curvilinear detail. That’s where badness lives.
Re liver enzymes: check out my post form a few months ago that I searched out on the forum search box to the left here serach word “enzymes”.
https://sonopath.com/forum/evaluating-benign-liver-coarse-liver-lumped-liver-grandma-liver-enzyme-chase-what-do-they-have
LEs are all over the map in variable pathology.. to me elevated LEs are just a reason to do a sonogram unless Bili GGT and blasting ALT AST are in play which means a hot parenchymal process or if DSAP is driving high rapidly which means an active congestive process. Low albumin and BUN are key parameters too.
Thanks
JP
Thanks
JP
Thanks
JP
Thanks
JP
Thanks
JP
Thanks
JP
Thanks
JP
Thanks
JP