45-year-old male with subacute cholestatic liver enzyme elevation with acute worsening of alkaline phosphatase in 300s one month ago at outside hospital, now 900s. Worsening of extensive tumor burden at multiple locations versus focal stentable obstruction secondary to malignancy. Exam limitations related to respiratory motion artifact.ABDOMEN:LIVER, BILIARY TRACT: Hepatomegaly measuring up to 20 cm in craniocaudal length. Numerous bilobar T2 hyperintense metastatic lesions predominantly of the right hepatic lobe relatively stable in size and number. Reference measurements listed below. As seen on the prior exam, there are 2 lesions extending beyond the hepatic capsule and into the right lateral and anterolateral subcutaneous tissues (axial series 5 images 26, 35). The lesions cause mass effect with narrowing of the intrahepatic IVC. There is marked attenuation versus possible occlusion of the main portal vein.Nonvisualization of the central right bile ducts due to multiple liver lesions. There are a few areas of mild intrahepatic biliary ductal dilatation measuring up to 7 mm in diameter (series 5 image 28). No extrahepatic biliary ductal dilatation. The common bile duct is at the upper limits of normal measuring 6.3 mm in diameter (coronal series 7 image 37). There is a possible abnormal soft tissue signal adjacent to the level of the bilioenteric anastomosis without significant biliary ductal dilatation (series 8 image 31).SPLEEN: Mild splenomegaly measuring 13 cm in length.PANCREAS: Status post Whipple procedure. No pancreatic ductal dilatation.ADRENAL GLANDS: No significant abnormality noted.KIDNEYS, URETERS: No significant abnormality noted.RETROPERITONEUM, LYMPH NODES: Retroperitoneal infiltrative nodal adenopathy is similar compared to to the prior CT exam. Mildly enlarged periportal lymph nodes are noted.BOWEL, MESENTERY: Status post Whipple CT. Large volume ascites. Diffuse submucosal edema is noted. Small bowel loops are mildly dilated measuring up to 3.8 cm in diameter. No definite evidence for obstruction, and an ileus is suspected. A right lower quadrant small drain is in place. Peritoneal thickening in the posterior right upper quadrant demonstrating subtle restricted diffusion is concerning for peritoneal disease (series 9 image 152).BONES, SOFT TISSUES: Worsening anasarca.OTHER: New bilateral pleural effusions.INDEX LESION MEASUREMENTS (Current exam date/time: 12/12/2016 09:00:00)HEPATIC SEGMENT 4A LESION: 0.4 cm (Image 25, Series 5); 5.7 x 4.6 cm (Image 20, Series 8); 5.6 x 4.4 cm on prior (12/4/2016) (Image 40, Series 6).
1.Numerous bilobar hepatic metastases with at least 2 lesions extending beyond the hepatic capsule into the subcutaneous tissues. Reference measurements listed above.2.There is possible abnormal soft tissue signal adjacent to the expected level of the bilioenteric anastomosis (could reflect nodal disease) without significant upstream biliary ductal dilatation. Few areas of mild intrahepatic biliary ductal dilatation (measuring up to 7 mm) also noted. Retroperitoneal infiltrative nodal adenopathy is similar compared to to the prior CT exam. Mildly enlarged periportal lymph nodes are seen.3.Large volume ascites with mild dilated small bowel loops and diffuse submucosal edema. Findings most suggestive of a reactive ileus.4.New bilateral pleural effusions and prominent anasarca. I personally reviewed the Images and/or procedure with the Resident/Fellow and agree with this report.