Question: A 53-year-old woman with a history of hypertension and nephrolithiasis presents with right lower quadrant nonradiating abdominal cramping. The patient underwent a screening colonoscopy the day prior with a 6-mm sessile polyp removed from the cecum via cold snare polypectomy. The abdominal pain started 12 hours after the colonoscopy and was associated with nausea and tactile fevers. She denied hematochezia or a change in bowel habits. On physical examination, she was febrile (38.8 C) and hemodynamically stable. The abdomen was soft with tenderness to palpation in the right lower quadrant without peritoneal signs. Laboratory values were significant for a white blood cell count 7.0 K/mL (reference range, 4.5-11.0 K/mL). A computed tomography scan of the abdomen was also completed (Figure A). What is the diagnosis? See the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI.

Hepatoid adenocarcinoma (HA) is a rare malignant tumor of extrahepatic origin that morphologically and immunophenotypically resembles hepatocellular carcinoma. We report a case of rectal HA with hepatic metastasis arising in a 38-year-old male with a history of ulcerative colitis. Despite elevated alpha-fetoprotein, contrast enhancement of the hepatic mass was not consistent with hepatocellular carcinoma. Immunohistochemistry revealed the diagnosis, and the patient was started on palliative chemotherapy. Colorectal HA should be considered when evaluating malignant lesions in the setting of inflammatory bowel disease and can be distinguished from other tumors based on alpha-fetoprotein, imaging, and immunostaining.

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