A Surprising Cause of Abdominal Pain and Bloating

Question: A 54-year-old woman presented with diffuse, crampy, episodic abdominal pain present for several years but recently worsening. There was occasional localization to the right upper quadrant and it was exacerbated with eating. She had nausea without emesis, no change in bowel habits, and no improvement with bowel movements. She denied dyspnea and lower extremity edema. Her history includes sulfa-induced hepatitis in 1987 at which time a percutaneous biopsy was performed. She recovered fully and had no other history of liver injury. She presented with normal vital signs. Examination elicited a soft, diffusely tender, minimally distended abdomen without evidence of ascites. Bowel sounds were hyperactive, and a bruit was auscultated over the right upper quadrant. She had no jaundice or scleral icterus. There was no jugular venous distension, extra heart sounds, or lower extremity edema. Lungs were clear to auscultation. Laboratory investigation including complete blood count, lipase, aspartate aminotransferase, alanine aminotransferase, alkaline phosphatase, and electrolytes were normal. Total bilirubin was 2.6 mg/dL, of which 2.0 mg/dL was unconjugated. Abdominal computed tomography obtained in urgent care (Figure A) showed a 4.5 3.2 5.3-cm, contrast-enhanced lesion in the periphery of the right hepatic lobe (arrow). Abdominal magnetic resonance imaging (MRI) and ultrasonography were performed. In T2-weighted sequencing (Figure B), MRI demonstrated contrast enhancement of hepatic artery (arrows) and vascular mass (arrowhead) in liver segment VIII. The celiac axis and hepatic artery were noted to be dilated to the same size as the common iliac arteries. T1 sequencing (Figure C) showed a 3.7 2.6-cm vascular mass in segment VII (arrow) and enhancement of the portal vein (arrowhead) during the arterial phase. Ultrasonography confirmed the vascular mass. There was hepatofugal flow in the portal vein. The liver echogenicity and echotexture were normal. The common bile duct was 4 mm. What is the diagnosis? Look on page 1165 for the answer and see the GASTROENTEROLOGY web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI.