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To the Editor:
A recently developed technique, spiral computed tomographic (CT) scanning, may be particularly useful in the identification of liver masses. Data indicate that hepatocellular carcinomas and other liver masses with a predominantly arterial blood supply are best detected during the arterial phase of contrast enhancement, which occurs between 20 and 40 seconds after the administration of intravenous contrast material. (1,2) Spiral CT scanning represents a technological advance and is the result of improvements in the efficiency of x-ray detection and continuous rotation of the x-ray tube. With spiral CT, an entire set of images of the liver can be obtained during the arterial phase of contrast enhancement.
An 85-year-old man with alcoholic cirrhosis had anorexia and truncal edema. Physical examination revealed visible periumbilical veins and a quiet, continuous murmur over the umbilicus. Abdominal CT scanning before the administration of intravenous contrast medium (iopamidol, Isovue 300, Bracco Diagnostics, Princeton, N.J.) showed ascites, splenomegaly, and a nodular liver without obvious mass lesions (Figure 1A). An image obtained during the arterial phase of contrast enhancement (Figure 1B) showed two hyperenhanced liver nodules (arrows). The masses were difficult to see on an image obtained during the standard portal venous phase (Figure 1C) because they were of the same density as the surrounding liver tissue.
A biopsy of one of the masses was performed with image guidance. Hepatocellular carcinoma was diagnosed. The patient was sent home with a request to receive only palliative care. He died three weeks later.
The image obtained during the portal venous phase (Figure 1C) shows a markedly enhanced recanalized umbilical vein (arrows) coursing along the falciform ligament and anterior abdominal wall, indicating the presence of portal hypertension. The combination of liver cirrhosis, dilated periumbilical veins, and a venous hum over the umbilicus is known as the Cruveilhier-Baumgarten syndrome. (3) High pressure in the portal venous system creates a portosystemic shunt through the remnants of the umbilical vein that communicates with abdominal-wall veins.
Klaus Mergener, M.D.
Erik K. Paulson, M.D.
John Baillie,
M.B., Ch.B.
Duke University Medical Center
Durham, NC
27710
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