A 54-year-old woman comes to the office due to fatigue, anorexia, and weight loss. Over the past 3 months, she has lost 10 kg (22 lb) but has not changed her diet or activity level. The patient has a history of hypertension and type 2 diabetes mellitus. She does not use tobacco, alcohol, or illicit drugs. Temperature is 36.9 C (98.4 F), blood pressure is 120/80 mm Hg, pulse is 80/min, and respirations are 16/min. BMI is 31 kg/m². Mild temporal wasting is noted. The abdomen is soft, the flanks are full, and shifting dullness is present. There is hepatomegaly and a single palpable liver nodule. Trace edema is present in the bilateral lower extremities. Laboratory results are as follows: Which of the following is the most likely diagnosis?

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Quizplus · Accepted Answer

This patient's ascites (shifting abdominal dullness), hypoalbuminemia, mildly elevated liver function tests, thrombocytopenia, and hyperbilirubinemia are consistent with underlying cirrhosis. Most cases are caused by alcohol abuse, chronic viral hepatitis, or nonalcoholic fatty liver disease (as is likely in this patient with a history of diabetes mellitus and obesity). Patients with cirrhosis are often unaware of the diagnosis until they develop complications such as variceal bleeding or hepatocellular carcinoma (HCC), a primary liver tumor. Risk of HCC in patients with cirrhosis is 1%-8% per year. In these patients, HCC usually presents with decompensated liver failure (eg, ascites, jaundice, hypoalbuminemia), weight loss, cachexia (eg, temporal wasting), possible hepatomegaly, and a palpable liver nodule. Alpha-fetoprotein (AFP), a glycoprotein produced by the fetal liver and yolk sac, is elevated in ~50% of cases; therefore, AFP can serve as an important diagnostic clue (when elevated) but cannot be used to rule out the diagnosis. Triple phase arterial contrast CT scan of the abdomen is diagnostic in most cases. (Choice A) Focal nodular hyperplasia is a benign liver lesion that usually arises in young women. Although a minority develop a palpable liver nodule, most are asymptomatic; the lesion does not usually rupture, undergo malignant transformation, cause liver failure, or result in weight loss/cachexia. (Choice B) Hepatic adenoma is a benign liver lesion common in young women on oral contraception. Some lesions undergo malignant transformation (to HCC), which may result in cachexia, weight loss, and anorexia. However, decompensated liver failure is uncommon (because the rest of the liver has preserved function). (Choice D) Hydatid cyst is an Echinococcus tapeworm infection. Most cases are asymptomatic, but large hydatid cysts can cause hepatomegaly, right upper quadrant pain, or nausea/vomiting. Decompensated liver failure and cachexia/weight loss would be uncommon. (Choice E) Pyogenic liver abscess is most common in the setting of biliary infection or bowel perforation. Although weight loss, anorexia, fatigue, transaminitis, hepatomegaly, and hyperbilirubinemia commonly occur, almost all patients have fever, abdominal pain, and leukocytosis. Educational objective: Patients with cirrhosis are often unaware of the condition until they develop complications. One major complication is hepatocellular carcinoma, a primary liver tumor that often presents with decompensated liver failure, weight loss, and a palpable liver lesion. Alpha-fetoprotein is elevated in ~50% of cases; therefore, it can be a useful diagnostic clue but cannot be used to rule out the disease.

A 54-Year-Old Woman Comes to the Office Due to Fatigue