Hepatocellular carcinoma (HCC) is increasingly being detected at an earlier stage, owing to the screening programs and regular imaging follow-up in high-risk populations. Small HCCs still pose diagnostic challenges on imaging due to decreased sensitivity and increased frequency of atypical features. Differentiating early HCC from premalignant or benign nodules is important as management differs and has implications on both the quality of life and the overall survival for the patients. Gadoxetate acid (Gd-EOB-DTPA, Primovist®, Bayer Schering Pharma) is a relatively new, safe and well-tolerated liver-specific contrast agent for magnetic resonance (MR) imaging of the liver that has combined perfusion- and hepatocyte-specific properties, allowing for the acquisition of both dynamic and hepatobiliary phase images. Its high biliary uptake and excretion improves lesion detection and characterization by increasing liver-to-lesion conspicuity in the added hepatobiliary phase imaging. To date, gadoxetate acid-enhanced MRI has been mostly shown to be superior to unenhanced MRI, computed tomography, and other types of contrast agents in the detection and characterization of liver lesions. This review article focuses on the evolving role of gadoxetate acid in the characterization of HCC, differentiating it from other mimickers of HCC.

C a s e R e p o r t e34 I NTRO D U C TIO NBiliary drainage procedures are widely used in the management of biliary-related diseases, benign or otherwise. As percutaneous transhepatic biliary drainage (PTBD) is an invasive procedure, it is not risk-free. Although no significant difference in the success rate of cannulation in patients with dilated and non-dilated biliary systems has been reported, PTBD-related complications are found to be higher when performed on non-dilated biliary systems and small cirrhotic livers.(1,2) Portobiliary fistula is a recognised, but uncommon, complication of PTBD and can result in significant haemobilia. (3,4) We herein present a case of portobiliary fistula following PTBD catheter insertion in a patient with an underlying history of hepatitis B liver cirrhosis. The portobiliary fistula was successfully managed using embolisation coils to occlude the fistulous tract. CA S E R EPO RTA 50-year-old man with underlying hepatitis B liver cirrhosis was investigated for anaemia. He was found to have a 5-cm fluorodeoxyglucose-avid duodenal mass arising from the second part of the duodenum, consistent with gastrointestinal stromal tumour (GIST). No distant metastasis was found.Transhepatic cholangiography was performed, together with preoperative insertion of a biliary drainage catheter before pancreaticoduodenectomy (i.e. Whipple's operation).The patient's liver was found to be grossly cirrhotic.Successful access to the left hepatic lobe segment 3 duct was achieved using a 22G Chiba needle (Pajunk GmbH, ABSTRACT Although portobiliary fistula is a recognised complication of percutaneous transhepatic biliary drainage, it is extremely uncommon and can result in haemobilia. Herein, we present a case of complicated transhepatic biliary drainage catheter insertion in a patient with underlying hepatitis B liver cirrhosis, which resulted in a portobiliary fistula. The patient had a preoperative transhepatic biliary drainage procedure done prior to a Whipple's operation for a large, obstructive, gastrointestinal stromal tumour of the duodenum. To the best of our knowledge, this is the first case in the English medical literature reporting the successful treatment of portobiliary fistula by embolisation of its tract with embolisation coils, without compromising the portal vein or bile ducts. Keywords: embolisation coil, haemobilia, portobiliary fistula, transhepatic biliary drainageSingapore Med J 2014; 55(3): e34-e36 doi: 10.11622/smedj.2014039

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With our proposed criteria, and scoring system, the selection of patients for CRS and HIPEC can be improved, and unnecessary exploratory operations avoided.

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