A 33-year-old woman comes to the office due to a dull, aching pain in the right upper quadrant of the abdomen for several weeks. Her medical history is unremarkable. She takes no medications except an oral contraceptive, which she has used for the past 12 years. The patient drinks 1 or 2 glasses of wine on social occasions but does not use tobacco or illicit drugs. Temperature is 36.7 C (98 F), blood pressure is 120/80 mm Hg, pulse is 78/min, and respirations are 14/min. BMI is 27 kg/m². Examination shows hepatomegaly with moderate discomfort on deep palpation in the right upper quadrant. There is no jaundice or ascites. Cardiopulmonary examination shows no abnormalities. Laboratory results are as follows: Abdominal ultrasonogram reveals a solitary hyperechoic 7-cm lesion in the right lobe of the liver. Which of the following is the most likely diagnosis in this patient?

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11ec25c8_d8f8_7149_bc81_9dd63065ff78_MD0003_00 This young woman has a large, painful hepatic mass. She has elevated alkaline phosphatase and gamma glutamyl transpeptidase (GGT) levels, suggesting biliary compression or obstruction, but otherwise relatively normal liver markers. In light of her minimal alcohol consumption and long-term use of oral contraceptives, this likely represents a hepatic adenoma. Hepatic adenomas are benign epithelial tumors that are most common in young and middle-age women. Additional risk factors include anabolic androgen use and pregnancy. Initial diagnosis is based on the clinical presentation and imaging studies. Ultrasound most commonly shows well-demarcated, hyperechoic lesions, and contrast-enhanced CT can show early peripheral enhancement. Needle biopsy is not recommended for suspected hepatic adenoma due to the risk of bleeding, and surgical excision is preferred. Possible long-term complications include progressive growth, rupture, and malignant transformation. Hepatic adenoma can clinically resemble focal nodular hyperplasia (FNH), a common mass lesion in young women caused by hyperperfusion from anomalous arteries. However, FNH is not associated with oral contraceptives, and imaging will show evidence of increased arterial flow and sometimes a central scar. (Choice B) Hepatocellular carcinoma is characterized by a rapidly enlarging liver mass, often with satellite lesions. It usually occurs in patients with cirrhosis or chronic hepatitis (especially hepatitis B) and would be unusual in a young patient without these risk factors. (Choice C) Hydatid cysts are caused by Echinococcus tapeworm infections. In the United States, most cases are seen in immigrants, although occasional cases may be seen in individuals from the Southwest who have been exposed to sheep and dogs. It causes cystic, not solid, liver lesions. (Choice D) Most patients with metastatic liver disease will have a known extrahepatic primary malignancy (eg, colon, pancreas). Although the liver lesions may occasionally be found prior to the primary tumor, most patients are older, have systemic symptoms (eg, weight loss), and often have multiple liver lesions. (Choice E) Acute or chronic liver injury can lead to nodular regeneration. This is usually multifocal and occurs most commonly in the setting of cirrhosis. Educational objective: Hepatic adenoma is a benign tumor most often seen in young and middle-age women who take oral contraceptives. Possible long-term complications include progressive growth, rupture, and malignant transformation. References: Hepatocellular adenoma: an update. (http://www.ncbi.nlm.nih.gov/pubmed/26557953)

A 33-Year-Old Woman Comes to the Office Due to a Dull