Intrahepatic Portal Vein Aneurysm with Concurrent Hepatocellular Carcinoma

Abstract

A 70-year-old male with a nine-year history of chronic hepatitis B infection and liver cirrhosis was admitted to the Kuala Lumpur General Hospital in Kuala Lumpur, Malaysia, in November 2012 with chills and jaundice. A physical examination revealed a distended abdomen without tenderness or masses. There were no other signs of chronic liver disease and the patient was haemodynamically stable. Liver function tests revealed elevated total bilirubin (172.0 μmol/L), alkaline phosphatase (163.0 U/L) and gamma-glutamyl transferase (134.0 U/L) levels. Alanine aminotransferase, white cell count and C-reactive protein levels were within normal limits. However, the patient's serum α-fetoprotein levels were elevated (919.3 ng/mL).An ultrasound examination of the abdomen showed a cirrhotic liver with fusiform dilatation of the right portal vein. Contrast-enhanced abdominal computed tomography (CT) confirmed the presence of a fusiform aneurysm of the distal right portal vein [ Figure 1]. The aneurysm measured 2.2 cm in diameter and the remainder of the right portal vein was also diffusely dilated. The main portal vein and its left branch, as well as the hepatic veins, were not dilated. These veins were patent with no filling defects to suggest thrombosis. The spleen was mildly enlarged (14.5 cm) and there were multiple varices in the perigastric region and splenic hilum. An illdefined mass in segment V of the liver was observed which demonstrated heterogeneous enhancement in the arterial phase and relative contrast washout in the portal venous phase. The greatest diameter of the enhancing component of the lesion in the arterial phase was 4.0 cm. There was extrinsic compression of the mass on the adjacent right intrahepatic duct resulting in dilatation of the proximal biliary system. A Figure 1A & B: Selected axial computed tomography images showing a concurrent portal venous aneurysm (asterisks) and a mass in segment V of the liver, most likely a hepatocellular carcinoma, in a 70-year-old male. The mass (white arrows) demonstrated (A) typical heterogeneous enhancement in the arterial phase and (B) washout in the portal venous phase. Additionally, it caused dilatation of the proximal intrahepatic biliary ducts (black arrows).interesting medical image

Portal vein aneurysm-etiology, multimodal imaging and current management

“…Long-standing portal hypertension causes intimal thickening with compensatory medial hypertrophy of the PV. Over time, medial hypertrophy is replaced by fibrous tissue, leading to weakening of the vein wall, thus making it susceptible to aneurysmal dilatation[ 12 , 13 ]. However, the incidence of portal hypertension and PVA is disproportionate, suggesting the existence of other contributory factors.…”

“…Aiming to clarify novelty as regards this visceral vascular abnormality, we performed a literature search of the PubMed database for all articles relating to PVA between January 2015 and July 2022[ 12 - 68 ]. We collected 57 reports, involving 62 patients with a PVA[ 3 - 7 , 12 - 16 , 19 , 21 - 25 , 27 , 29 - 68 ]; we also found one retrospective study with 18 PVA patients[ 2 ], and three cases of PV pseudoaneurysm[ 69 - 71 ].…”

Congenital Intrahepatic Portal Vein Aneurysm Associated with Left Kidney Hypoplasia as Incidental Imaging Findings in An Adult– A Case Study

“…The paraclinical status revealed no markers of hepatitis viruses, but a mild increase in gamma-glutamyl transferase (GGT) of 56.77 U/l (normal range 0-55 U/l), unusual in isolated PVA but higher values in association hepatocellular carcinoma [15]; alanine aminotransferase (ALAT) had increased values, too, up to 50.52 u/l (normal range 0-41 u/l), but normal aspartate aminotransferase (AST); the hepatoprotective treatment resulted in normalizing of these enzymes. The serum urea and creatinine were in normal limits, while a mild microcytic anemia was treatmentresistant: hemoglobin of 10.3-10.8 g/dL (normal 12.5-15.5 g/dL), hematocrit of 31.9%-34.6% (normal 37%-47%), mean corpuscular volume (MCV) of 71.4-75,5 fl (82-98 fl), mean corpuscular hemoglobin (MCH) of 23.0-23.1 pg (26-34 pg).…”

Thrombosis of a portal vein aneurysm: a case report with literature review

“…Inflammation or local injury in these latter cases could weaken the vessel walls, leading to aneurysmal dilatation. Some PVAs have been described in association with hereditary hemorrhagic telangiectasia [10]. Acquired PVAs, especially when combined with liver disease and portal hypertension, have a more unpredictable course and warrant a closer follow-up and more aggressive intervention when complications occur [11].…”

“…Surgical intervention has been proposed, but remains controversial. The management of PVA should be decided on a case-by-case basis, depending on symptoms, presence of cirrhosis, and size and anatomy of PVA [10]. Currently, surgery is considered in some cases of complicated PVA, that is, in severely symptomatic patients, expanding aneurysm, coexistence of mass effect on adjacent structures, thrombosis, or rupture [14].…”