Liver mass differential diagnosis

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Maria Fernanda Villarreal, M.D. [2]; Dildar Hussain, MBBS [3]; Aditya Ganti M.B.B.S. [4]

Overview

Liver mass must be differentiated from the diseases that cause abdominal pain, pruritus, low-grade fever, and ascities such as angiomyolipoma, adenoma, borderline (high-grade dysplastic) nodule, cholangiocarcinoma, confluent fibrosis, focal nodular hyperplasia, focal fat sparing and deposit on liver, gallbladder cancer, hereditary hemorrhagic telangiectasia, inflammatory pseudotumors, liver hemangioma, hepatoblastoma in children, pyogenic liver abscesses, pancreatic cancer, Stomach cancer.

Common Differential Diagnosis

Liver mass must be differentiated from the following diseases that cause abdominal pain, pruritus, low-grade fever, and ascities such as:[1][2][3][4][5][6][7][8][9][10][11][12][13][14][15][16][16][17][18][19][20][21][22][13][23][24][25][26][27]

Abbreviations: RUQ= Right upper quadrant of the abdomen, LUQ= Left upper quadrant, LLQ= Left lower quadrant, RLQ= Right lower quadrant, LFT= Liver function test, SIRS= Systemic inflammatory response syndrome, ERCP= Endoscopic retrograde cholangiopancreatography, IV= Intravenous, N= Normal, AMA= Anti mitochondrial antibodies, LDH= Lactate dehydrogenase, GI= Gastrointestinal, CXR= Chest X ray, IgA= Immunoglobulin A, IgG= Immunoglobulin G, IgM= Immunoglobulin M, CT= Computed tomography, PMN= Polymorphonuclear cells, ESR= Erythrocyte sedimentation rate, CRP= C-reactive protein, TS= Transferrin saturation, SF= Serum Ferritin, SMA= Superior mesenteric artery, SMV= Superior mesenteric vein, ECG= Electrocardiogram

Disease Clinical manifestations Diagnosis Comments
Symptoms Signs
Abdominal Pain Fever Rigors and chills Nausea or vomiting Jaundice Constipation Diarrhea Weight loss GI bleeding Hypo-

tension

Guarding Rebound Tenderness Bowel sounds Lab Findings Imaging
Hepatocellular carcinoma/Metastasis RUQ + + + + + + + + +
  • Normal
  • Hyperactive if obstruction present

Other symptoms:

Cholangiocarcinoma RUQ + + + + + Normal
  • Predisposes to pancreatic cancer
Pancreatic carcinoma MidEpigastric + + + + + Normal

Skin manifestations may include:

Focal nodular hyperplasia Diffuse ± ± + + Normal
  • Open biopsy if diagnosis can not be established
Disease Abdominal Pain Fever Rigors and chills Nausea or vomiting Jaundice Constipation Diarrhea Weight loss GI bleeding Hypo-

tension

Guarding Rebound Tenderness Bowel sounds Lab Findings Imaging Comments
Gallbladder cancer Midepigastric + + + + Normal
Liver hemangioma Intermittent RUQ + + Normal
  • Abnormal LFTs
Liver abscess RUQ + + + + Normal
  • US
  • CT
Cirrhosis RUQ+Bloating + + + + Normal US
  • Stigmata of liver disease
  • Cruveilhier- Baumgarten murmur
Inflammatory lesions RUQ ± + + Normal US
  • Nodular,shrunken or coarse liver
  • Stigmata of liver disease

References

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  2. Guo, Le-Hang; Xu, Hui-Xiong (2015). "Contrast-Enhanced Ultrasound in the Diagnosis of Hepatocellular Carcinoma and Intrahepatic Cholangiocarcinoma: Controversy over the ASSLD Guideline". BioMed Research International. 2015: 1–5. doi:10.1155/2015/349172. ISSN 2314-6133.
  3. Wilson, Stephanie R.; Kim, Tae Kyoung; Jang, Hyun-Jung; Burns, Peter N. (2007). "Enhancement Patterns of Focal Liver Masses: Discordance Between Contrast-Enhanced Sonography and Contrast-Enhanced CT and MRI". American Journal of Roentgenology. 189 (1): W7–W12. doi:10.2214/AJR.06.1060. ISSN 0361-803X.
  4. Ohtomo K, Baron RL, Dodd GD, Federle MP, Miller WJ, Campbell WL, Confer SR, Weber KM (1993). "Confluent hepatic fibrosis in advanced cirrhosis: appearance at CT". Radiology. 188 (1): 31–5. doi:10.1148/radiology.188.1.8511316. PMID 8511316.
  5. Wu, Jim S.; Saluja, Sanjay; Garcia-Tsao, Guadalupe; Chong, Alice; Henderson, Katherine J.; White, Robert I. (2006). "Liver Involvement in Hereditary Hemorrhagic Telangiectasia: CT and Clinical Findings Do Not Correlate in Symptomatic Patients". American Journal of Roentgenology. 187 (4): W399–W405. doi:10.2214/AJR.05.1068. ISSN 0361-803X.
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  7. {{cite
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  12. Brannigan, Margot; Burns, Peter N.; Wilson, Stephanie R. (2004). "Blood Flow Patterns in Focal Liver Lesions at Microbubble-enhanced US". RadioGraphics. 24 (4): 921–935. doi:10.1148/rg.244035158. ISSN 0271-5333.
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  14. Jang, Hyun-Jung; Kim, Tae Kyoung; Lim, Hyo Keun; Park, Sang Jae; Sim, Jung Suk; Kim, Hyae Young; Lee, Joo-Hyuk (2003). "Hepatic Hemangioma: Atypical Appearances on CT, MR Imaging, and Sonography". American Journal of Roentgenology. 180 (1): 135–141. doi:10.2214/ajr.180.1.1800135. ISSN 0361-803X.
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  17. Bhayana, Deepak; Kim, Tae Kyoung; Jang, Hyun-Jung; Burns, Peter N.; Wilson, Stephanie R. (2010). "Hypervascular Liver Masses on Contrast-Enhanced Ultrasound: The Importance of Washout". American Journal of Roentgenology. 194 (4): 977–983. doi:10.2214/AJR.09.3375. ISSN 0361-803X.
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  20. Alturkistany, Samira; Jang, Hyun-Jung; Yu, Hojun; Lee, Kyoung Ho; Kim, Tae Kyoung (2011). "Fading hepatic hemangiomas on multiphasic CT". Abdominal Radiology. 37 (5): 775–780. doi:10.1007/s00261-011-9826-6. ISSN 2366-004X.
  21. Liu GJ, Lu MD, Xie XY, Xu HX, Xu ZF, Zheng YL, Liang JY, Wang W (2008). "Real-time contrast-enhanced ultrasound imaging of infected focal liver lesions". J Ultrasound Med. 27 (4): 657–66. PMID 18359914.
  22. Kim, Kyoung Won; Choi, Byung Ihn; Park, Seong Ho; Kim, Ah Young; Koh, Young Hwan; Lee, Hyun Ju; Han, Joon Koo (2004). "Pyogenic hepatic abscesses: distinctive features from hypovascular hepatic malignancies on contrast-enhanced ultrasound with SH U 508A; early experience". Ultrasound in Medicine & Biology. 30 (6): 725–733. doi:10.1016/j.ultrasmedbio.2004.03.006. ISSN 0301-5629.
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  24. Menias, Christine O.; Surabhi, Venkateswar R.; Prasad, Srinivasa R.; Wang, Hanlin L.; Narra, Vamsi R.; Chintapalli, Kedar N. (2008). "Mimics of Cholangiocarcinoma: Spectrum of Disease". RadioGraphics. 28 (4): 1115–1129. doi:10.1148/rg.284075148. ISSN 0271-5333.
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  27. CHEDID, Marcio F.; KRUEL, Cleber R. P.; PINTO, Marcelo A.; GREZZANA-FILHO, Tomaz J. M.; LEIPNITZ, Ian; KRUEL, Cleber D. P.; SCAFFARO, Leandro A.; CHEDID, Aljamir D. (2017). "HEPATOCELLULAR CARCINOMA: DIAGNOSIS AND OPERATIVE MANAGEMENT". ABCD. Arquivos Brasileiros de Cirurgia Digestiva (São Paulo). 30 (4): 272–278. doi:10.1590/0102-6720201700040011. ISSN 2317-6326.


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