Differentials
Cholangiocarcinoma
SIGNS / SYMPTOMS
Progressive obstructive jaundice, pruritus, clay-coloured stools, and dull right upper quadrant abdominal pain in late stage.
INVESTIGATIONS
Transaminases, prothrombin time/INR, and AFP are usually normal or mildly elevated. Patients typically have elevated bilirubin, alkaline phosphatase, and gamma-glutamyl transferase.
Cancer antigen (CA) 19-9 may be elevated.
There may be dilated bile ducts on ultrasound or CT scan of the abdomen.
Endoscopic retrograde cholangiopancreatography or magnetic resonance cholangiopancreatography are very helpful in diagnosis.
Hepatic adenoma
SIGNS / SYMPTOMS
Patients are usually asymptomatic but can rarely present with acute abdominal pain, right upper quadrant tenderness, and shock due to haemoperitoneum.
INVESTIGATIONS
On ultrasound or CT scan of the abdomen, the adenoma appears as a very well circumscribed subcapsular hypo-echoic lesion. Doppler blood flow shows venous pattern instead of the arterial hypervascularisation pattern of HCC.
Patients generally have normal AFP.
Haemangioma of liver
SIGNS / SYMPTOMS
Typically asymptomatic. Acute abdominal pain can result from thrombosis or bleeding within the haemangioma due to the stretching and inflammation of the Glisson capsule of the liver. Co-existent chronic liver disease is rare in these patients.
INVESTIGATIONS
Normal liver function tests and normal AFP.
The majority of hepatic haemangiomas are well demarcated, smooth, and hypodense with a homogeneous appearance on ultrasound, CT scan, or MRI of the abdomen. MRI is very sensitive and specific for these lesions.
Fibrolamellar HCC
SIGNS / SYMPTOMS
Patients may present with abdominal pain and/or palpable mass in the abdomen. It is not associated with chronic liver disease, cirrhosis, or hepatotoxins. Usually occurs in adolescents or young adults.[68]
INVESTIGATIONS
Liver function tests and AFP are usually normal or slightly elevated.
Typical stellate central scar is found on CT scan or MRI of the abdomen.
CT scan is the preferred test for diagnosis, staging, and postoperative follow-up. There may be regional lymph node involvement in 50% to 70% of patients due to aggressiveness of the tumour.
Typical liver histology includes a pattern of nests, sheets, or cords of malignant cells separated by lamellar bands of dense, hypocellular, and collagenous connective tissue.
Focal nodular hyperplasia (FNH)
SIGNS / SYMPTOMS
One third of patients may have abdominal discomfort or palpable liver mass.
There is no history of chronic liver disease in patients with FNH.
INVESTIGATIONS
Liver function tests and AFP are within normal range.
Presence of central scar on ultrasound, CT scan, MRI scan, or technetium sulfur colloid scanning of abdomen is diagnostic in the majority of cases. Tissue diagnosis is not needed.
Metastatic liver disease
SIGNS / SYMPTOMS
Patients may have signs and symptoms of primary cancer, but in many cases they are diagnosed after liver metastasis is found. The liver may be the site of metastasis from virtually any primary malignant neoplasm, but the most common primary sites are colon, stomach, pancreas, breast, lung, neuro-endocrine tumours, and eye.
INVESTIGATIONS
Dynamic contrast-enhanced CT of the abdomen is very sensitive (80% to 90%) and specific (99%) in differentiating metastatic liver cancer from HCC. Gadolinium-enhanced MRI scan, positron emission tomography scan, and CT arteriography of the abdomen are very helpful in diagnosing liver metastatic disease, but are not essential.
Hepatic cyst
SIGNS / SYMPTOMS
Cysts are usually incidental findings; they do not cause any symptoms until they become enlarged (more than 5-6 cm). There is no association with chronic liver diseases or viral hepatitis.
INVESTIGATIONS
On ultrasound or CT scan of the abdomen, simple cysts appear as thin-walled cysts. Hydatid cysts usually have daughter cysts. Patients with polycystic liver-disease have multiple cysts. Unlike HCC, cystadenoma or cystadenocarcinoma does not usually have any calcification, and these cysts usually have internal septations.
Epithelioid haemangioendothelioma
SIGNS / SYMPTOMS
Symptoms are non-specific, including weight loss or right upper quadrant discomfort. There is no association with chronic liver disease.
INVESTIGATIONS
Liver function tests are normal unless patients have advanced disease.
Doppler ultrasound or CT of the abdomen shows vascular lesion.
Histology is diagnostic and usually positive for endothelial markers factor VIIIR:Ag (vWF), CD34, and CD31.
Liver abscess
SIGNS / SYMPTOMS
Associated with acute onset fever and right upper quadrant tenderness. There is no association with chronic liver disease.
INVESTIGATIONS
Air-fluid levels can be seen on imaging studies.
Patients usually have normal AFP.
Cultures are diagnostic but can be normal.
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