Wright Center for Graduate Medical Education Scranton, PA, United States
Beshir Saeed, MD1, Khalid Ahmed, MD1, Abdul Ahad Ehsan Sheikh, MD2, Mohammad Asim Amjad, MBBS, MD1 1Wright Center for Graduate Medical Education, Scranton, PA; 2Wright Center for GME, Scranton, PA
Introduction: Acute Liver Failure (ALF) caused by malignant infiltration to the liver without any notable imaging findings is rare. Metastatic adenocarcinoma is aggressive and usually the prognosis is poor at the time of diagnosis. We report a unique case of ALF caused by metastatic adenocarcinoma without any evidence of primary tumor or imaging findings.
Case Description/Methods: A 61 year old gentleman presented to the hospital with altered mentation for one day. Notable physical examination findings included tachycardia, asterixis, hepatomegaly and signs of dehydration. Investigations revealed hyperammonemia, deranged Liver markers elevated INR and evidence of kidney injury with a MELD-Na score of 25. Imaging showed hepatomegaly with nodular contour, incidental gallstones and normal appearing pancreas. Further workup revealed unremarkable iron studies, ceruloplasmin levels, hepatitis serology panels, ANA, ANCA, anti smooth muscle antibodies, and anti mitochondrial antibodies. Abdominal paracentesis ruled out SBP. Venous duplex ruled out portal and hepatic thrombosis. Non-Alcoholic fatty liver disease (NAFLD) was highly suspected until tumor markers revealed normal AFP, elevated CEA and markedly elevated CA 19-9 at 17,492 units/ml. MRCP was unable to be performed due to abdominal girth. Liver biopsy confirmed the diagnosis of poorly differentiated adenocarcinoma suggestive of Intra/Extrahepatic Cholangiocarcinoma versus pancreatic carcinoma. Supportive measures were instituted; however, patients' clinical status continued to deteriorate with eventual transition to hospice care.
Discussion: Infiltrating hepatic malignancy is associated with a poor prognosis and aggressive course of clinical deterioration. Liver transplantation is contraindicated and chemotherapeutic modalities are limited by multi organ failure. It is interesting to note that in our patient imaging demonstrated a nodular liver contour suggestive of cirrhosis without any notable liver masses. This led to the working diagnosis of NAFLD given patients history of diabetes mellitus, dyslipidemia and morbid obesity. Physicians should be aware of these conditions as diagnosis can be challenging and imaging can be normal or misleading. Hence, early recognition of malignancy and raising the index of suspicion for malignant infiltration as a potential cause of acute liver failure with an unknown etiology is crucial.
Disclosures: Beshir Saeed indicated no relevant financial relationships. Khalid Ahmed indicated no relevant financial relationships. Abdul Ahad Ehsan Sheikh indicated no relevant financial relationships. Mohammad Asim Amjad indicated no relevant financial relationships.
Beshir Saeed, MD1, Khalid Ahmed, MD1, Abdul Ahad Ehsan Sheikh, MD2, Mohammad Asim Amjad, MBBS, MD1. P0778 - A Mysterious Case of a Dying Liver: A Diagnostic Dilemma, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.