Multiple Hepatic Lesions found Incidentally

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Image Source: The New England Journal of Medicine

Medical conditions found incidentally are the only kind of surprises no one wants.

Imagine finding out a disease or lesion or mass when it is least expected.

This happened with a 45-year-old woman who unexpectedly surprised by multiple hepatic lesions that were incidentally noted on imaging that was done for an unrelated reason. She neither had any relevant symptoms, nor the physical examination revealed any positive findings.

Serological tests were also normal with normal alanine aminotransferase, alkaline phosphatase, bilirubin, and a normal international normalized ratio, thus no hepatic dysfunction.

Further imaging studies were conducted to evaluate the lesions. Enhanced computed tomography of the abdomen revealed numerous, small, hypodense, non-enhancing nodules spread across the liver (Panel A). Magnetic resonance imaging with cholangiopancreatography revealed a “starry sky” appearance with multiple, small, T2-weighted, hyperintense cystic nodules throughout the liver, with no biliary duct communication (Panel B).

A diagnosis of biliary hamartomas was made.

No specific treatment is required; therefore, the patient was given none. At 2 year-follow-up, the imaging findings were unchanged.

Von Mayenburg complex (VMCs), also called biliary hamartomas are benign congenital malformations of the intrahepatic biliary ducts due to failure of embryonic involution. These are found incidentally on ultrasound and require further evaluation to be sure of the diagnosis as it can be confused with extra-hepatic metastatic disease, polycystic liver disease, abscesses, and diffuse hepatocellular carcinoma. In some cases, a histopathological evaluation may be necessary too.

Biliary hamartomas show no enhancement on the CT scan and are well-defined with distinct margins.

Biliary hamartomas may be single or multiple and are usually asymptomatic. Larger lesions may produce a compressive effect exhibiting as jaundice and portal hypertension. Usually, they measure less than 5mm in size, but the sizes may vary from 1mm to 15mm.

Biliary hamartomas can be classified according to the degree of hamartoma consistency/biliary dilatation, into the following three classes:

Class 1: Solid pattern with narrow bile channels

Class 2: Intermediate pattern

Class 3: Marked cystic dilatation of bile ducts within the lesions

If the diagnosis is confirmed and the patient is asymptomatic, no treatment is required. If need be, the lesions can be followed up to look for any changes in the sizes and severity.

References:

Zheng RQ, Zhang B, Kudo M, Onda H, Inoue T. Imaging findings of biliary hamartomas. World J Gastroenterol. 2005;11(40):6354‐6359. doi:10.3748/wjg.v11.i40.6354

Barboi OB, Moisii LG, Albu-Soda A, Ciortescu I, Drug V. Biliary Hamartoma. Clujul Med. 2013;86(4):383‐384.

Takafumi Taguchi, M. P. (2020, April 16).“Starry Sky” Appearance from Multiple Biliary Hamartomas. Retrieved from The New England Journal of Medicine:
https://www.nejm.org/doi/full/10.1056/NEJMicm1909482

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Dr. Arsia Hanif has been a meritorious Healthcare professional with a proven track record throughout her academic life securing first position in her MCAT examination and then, in 2017, she successfully completed her Bachelors of Medicine and Surgery from Dow University of Health Sciences. She has had the opportunity to apply her theoretical knowledge to the real-life scenarios, as a House Officer (HO) serving at Civil Hospital. Whilst working at the Civil Hospital, she discovered that nothing satisfies her more than helping other humans in need and since then has made a commitment to implement her expertise in the field of medicine to cure the sick and regain the state of health and well-being. Being a Doctor is exactly what you’d think it’s like. She is the colleague at work that everyone wants to know but nobody wants to be. If you want to get something done, you approach her – everyone knows that! She is currently studying with Medical Council of Canada and aspires to be a leading Neurologist someday. Alongside, she has taken up medical writing to exercise her skills of delivering comprehensible version of the otherwise difficult medical literature. Her breaks comprise either of swimming, volunteering services at a Medical Camp or spending time with family.

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