A Curious Case of Contraception Royal Victoria Hospital

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A Curious Case of Contraception

A Curious Case of Contraception

Royal Victoria Hospital, Belfast.

Royal Victoria Hospital, Belfast.

CLINICAL INFORMATION • 24 y/o female. • Severe, sudden onset ‘RUQ’ pain • Vomiting

CLINICAL INFORMATION • 24 y/o female. • Severe, sudden onset ‘RUQ’ pain • Vomiting • Rigors • No past medical history • Drug history: Combined oral contraceptive pill (COCP) • On admission: • LFTs: bil 43, ALP 56, ALT 35, GGT 44, albumin 50. • WCC 12

SEQUENCE OF IMAGING EVENTS… • USS abdomen January 2017 - ? Cholelithiasis • MRCP

SEQUENCE OF IMAGING EVENTS… • USS abdomen January 2017 - ? Cholelithiasis • MRCP June 2017 - ? Biliary tract obstruction or cholelithiasis • CT liver June 2017 to investigate for liver lesion • MRI liver with contrast August 2017 • US-guided liver biopsy September 2017

USS abdomen

USS abdomen

Portal venous phase CT Unenhanced CT Arterial phase CT

Portal venous phase CT Unenhanced CT Arterial phase CT

MRCP

MRCP

In and Opposed-phase MRI

In and Opposed-phase MRI

ADC MAP T 2 TRIM DWI

ADC MAP T 2 TRIM DWI

PRIMOVIST LIVER 60 seconds Pre-contrast 30 seconds

PRIMOVIST LIVER 60 seconds Pre-contrast 30 seconds

5 minutes 90 seconds 120 seconds

5 minutes 90 seconds 120 seconds

5 minutes Precontrast 60 seconds

5 minutes Precontrast 60 seconds

DIFFERENTIAL DIAGNOSIS • Vascular anomaly? • Hepatic insufficiency? • Hepatic peliosis? • Sinusoidal dilatation

DIFFERENTIAL DIAGNOSIS • Vascular anomaly? • Hepatic insufficiency? • Hepatic peliosis? • Sinusoidal dilatation syndrome? • Lace-like fibrosis?

What next?

What next?

Final diagnosis Hepatic sinusoidal dilatation

Final diagnosis Hepatic sinusoidal dilatation

PATHOLOGIST'S REPORT Both cores of liver parenchyma demonstrate a normal hepatic lobular architecture with

PATHOLOGIST'S REPORT Both cores of liver parenchyma demonstrate a normal hepatic lobular architecture with adequate numbers of portal areas present for evaluation. These show no abnormality and specifically no evidence of any inflammatory process or cholangiopathy. Patchy sinusoidal dilatation is seen within both cores mainly in a zone 2/3 distribution. There is mild atrophy of hepatocytes associated with sinusoidal dilatation but no sinusoidal fibrosis no perivenular hepatocyte necrosis, no venous thrombosis and no blood filled spaces. In summary the only histological abnormality within the liver parenchyma represented is that of sinusoidal dilatation. This has a range of associations but, in this age group, it is mostly commonly encountered secondary to use of oral contraceptives. Note however that sinusoidal dilatation may also be encountered adjacent to or as part of the septum of vascular injury due to hepatic vein thrombosis (Budd-Chiari syndrome) or peliosis hepatis. Correlation with imaging appearances is required to excluded these diagnoses. LIVER CORE NEEDLE BIOPSY SINUSOIDAL DILATATION

DISCUSSION • Hepatic sinusoids are vascular channels which connect the portal triad to the

DISCUSSION • Hepatic sinusoids are vascular channels which connect the portal triad to the central venule • Sinusoidal dilatation causes luminal stasis causing resultant heterogenous enhancement of liver parenchyma • Multiple associations including pregnancy, HIV, oral contraceptive pill, neoplasm and granulomatous disease • Usually presents with RUQ pain, hepatomegaly and mildly deranged LFTs

Our patient… • Discontinued combined oral contraceptive pill • LFT’s have now returned to

Our patient… • Discontinued combined oral contraceptive pill • LFT’s have now returned to normal • Still experiencing intermittent RUQ pain • Under investigation for Sphincter of Oddi dysfunction under Hepatology team

Learning points… • Rare diagnosis of hepatic sinusoidal dilatation should be considered in heterogeneous

Learning points… • Rare diagnosis of hepatic sinusoidal dilatation should be considered in heterogeneous hepatic enhancement pattern on CT/MRI. • Histo-pathological confirmation following liver biopsy • Definitive diagnosis took approximately 9 months following initial presentation • Biochemical regression of disease after discontinuation of COCP

MANY THANKS!

MANY THANKS!

AUTHORS Dr. Michael Pyper; ST 4. Dr. Maria Mc. Gill; ST 5. Dr. Raghuram

AUTHORS Dr. Michael Pyper; ST 4. Dr. Maria Mc. Gill; ST 5. Dr. Raghuram Sathyanarayana; Consultant Interventional and GI Radiologist.