Expert intervention helps patient with a 3.5 cms
SOL in the right lobe of the Liver with Cirrhosis

Recently a young man of 32 years came to Nanavati Super Speciality Hospital with distension of the abdomen and Jaundice since the past 2 weeks along with abnormal sensorium. He had a long history of about 20 years of consultations with other Gastroenterologist in the past. He was diagnosed with extrahepatic portal venous obstruction. There was no history of ascites or appearance of Jaundice.

The patient had undergone Ogd and EVL several times in the past. Examination showed he had tense ascites along with deep icterus and little incoherence. On evaluation, he was found to have 3.5 cms SOL in the right lobe of the liver with Cirrhosis. The patient was found to be negative for serology and other treatable causes of Cirrhosis. Based on Milan’s criteria, he was advised for Liver Transplantation as a curative treatment.

He was evaluated for a Liver Transplant; however, during the course of the evaluation, he developed Sepsis (Staphylococcus in the blood) and SBP and Coagulopathy along with severe Hemolysis (DCT positive 3+) a Paraneoplastic Syndrome feature. The patient's condition improved with antibiotics and high doses of steroid as advised by our Haematologist but was instituted to lower doses for fear of recurrent SBP or fungal Sepsis. The patient improved over a couple of days.

EHPVO patients only have Variceal Bleed as the first presentation without any ascites, icterus or encephalopathy and they need repeated EVL and close follow up. They behave like compensated CLD and also have coarse echotexture on USG. To differentiate between Cirrhosis and EHPVO, FibroScan or MR Elastography or liver biopsy in some equivocal cases should be used.

Initially, the patient did not have any ascites, deep Jaundice or Encephalopathy and these compensated statuses were misinterpreted as EHPVO disease. The patient decompensated for the first time with the appearance of ascites, mild encephalopathy and jaundice. Any sudden decompensation in patients suspected with CLD is a clue for HCC or PVT. Being a Gastroenterologist, our goal is to prevent the development of Cirrhosis in any Chronic Hepatitis. Patient care and proper surveillance of Cirrhotic patients is vital to check the development of HCC.

Hepatocellular Carcinoma (HCC) is a primary malignancy of the liver and occurs predominantly in patients with underlying chronic liver disease and Cirrhosis. Presentation of HCC is now increasingly recognised at a much earlier stage in comparison to the past as a consequence of the routine screening of patients with known cirrhosis using crosssectional imaging studies.

There is also a growing problem with Cirrhosis, which develops in the setting of Non-alcoholic Fatty Liver Disease (NAFLD), or Non-alcoholic Steatohepatitis (NASH). NASH patients have more chances of developing HCC in comparison to ALD or other causes of Cirrhosis and needs stringent surveillance programme.

A point to note here is that he had been examined by several Physicians and Gastroenterologist, but was never evaluated for Cirrhosis which is a pre-malignant condition. 1

Dr. Purushottam

Dr. Purushottam
& Hepatologist
Nanavati Super
Speciality Hospital