2.1 Case History, Examination and Diagnosis
A 74-year-old lady presented with right upper abdominal pain and lump associated with early satiety for three months. There was no history of fever or jaundice. She was a smoker for 50 pack years and had hypertension and chronic obstructive airway disease (COPD). A general physical examination revealed stable vitals parameters with body mass index of 20.7 kg/m2. Abdominal examination revealed non-tender, smooth 5cm x 5cm smooth lump over the epigastrium. Blood investigation revealed a normal hemogram and liver function test with an alkaline phosphatase of 61 U/ml. Serum Cancer antigen (CA) 19-9 and carcinoembryonic antigen (CEA) were 7.8 U/ml and 0.5 ng/ml, respectively. Cyst fluid CEA was 0.5 ng/ml and was negative for malignant cells. Although the string test was suggestive, objective evidence of mucin could not be evaluated at our hospital. Transabdominal ultrasonography showed a large, well-defined cystic lesion with internal septation and no internal vascularity in the left lobe of the liver. Subsequently contrast enhanced computed tomography (CECT) of the abdomen (Fig 1a &1b) showed a hepatic cyst in segment IV and Spigelian caudate lobe with few enhancing septation with adjacent transient hepatic attenuation difference with compression and atrophy of the left lobe of the liver. The atrophic left lobe had a dilated intrahepatic biliary duct, and there was communication of a few bile ducts with the cyst. (Figure 1a & 1b)