A 78-year-old smoker was referred to the medical clinic for weight loss of 5kg in the past few months. This was associated with malaise. He denies abdominal pain, yellowing of sclera or tea-coloured urine. He has a history of chronic obstructive pulmonary disease and is an ex-intravenous drug user.
•Afebrile, pulse 68 bpm, BP 122/70mmHg, SaO2 98-100% on RA.
•Hydration fair, cachexic.
•Examination of the hands reveals no clubbing and normal-appearing palmar creases.
•Head and neck examination is unremarkable.
•Cardiovascular: HS dual, no murmur.
•His chest is clear on auscultation.
•Abdominal examination reveals a soft abdomen, with irregular hepatomegaly ~1-2cm below the right subcostal margin. There is no shifting dullness.
•No signs of oedema.
–WBC 5.7 x 109/L;
–platelets 163 x 109/L.
•ALP 110 IU/L.
•ALT 44 IU/L.
•Alpha-fetoprotein (AFP) 34μg/L.
•Adjusted calcium normal.
•Anti-HCV Ab positive.
What is your working diagnosis?
In view of a history of intravenous drug use and hepatitis C status, together with the constitutional symptoms, irregular hepatomegaly on palpation and raised AFP, hepatocellular carcinoma (HCC) is an important differential diagnosis. Another differential diagnosis includes liver metastases.
How would you proceed?
A triphasic computed tomography (CT) scan of the liver should be arranged (Figures 12.1–12.3).