2011 Radiology Exam - Abdomen Case 2

HISTORY: 5 year old neutered male Bouvier with weight loss, acute onset of anorexia, and jaundice.

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OBSERVATION:

• Evidence of hepatomegaly – caudal and left displacement of the stomach; rounded hepatic margins with irregular appearance of the serosal surface.
• Evidence of splenomegaly – enlargement of the head of the spleen with rounded margin and irregular appearance of the serosal surface; ill-defined soft tissue opacity extending from craniodorsal to caudoventral caudal to the stomach.
• Generalized loss of serosal detail. 

SYNTHESIS:

• The presence of concurrent hepatic and splenic enlargement is most consistent with an infiltrative disease affecting multiple organs – differentials include lymphosarcoma, histiocytic sarcoma and mast cell disease.
• Free abdominal fluid – most likely a neoplastic effusion.

PLAN:

• Abdominal ultrasound for further assessment AND fine-needle aspiration / biopsy of the affected organs.

Successful candidates identified enlargement and irregular margination of the liver and spleen and the loss of serosal detail. These candidates were then able to correlate the findings as most likely due to a single disease process and mentioned one or more of the differential diagnoses listed above.

Approximately 50% of the candidates did not associate the presence of concurrent hepatic and splenic enlargement with the presence of an infiltrative disease affecting multiple organs.

Some candidates gave a long list of differentials for hepatomegaly, a separate long list of differentials for splenomegaly but did not consider that enlargement of the organs was due to the same disease process.
Based on the rounded appearance of the central hepatic margin and the leftward displacement of the stomach some candidates diagnosed a liver mass and gave appropriate differentials. These canididates failed to identify the generalized hepatic enlargement or splenic enlargement.

Some candidates identified both hepatomegaly and splenomegaly but gave a primary differential of infectious / inflammatory disease affecting both organs. For many candidates this ranking of possible diagnoses appeared to be based on the age of the patient.