62-year-old male with history of cholangiocarcinoma, possibly metastatic. History of NSTEMI. Septic shock, concern for abscess. Hypotensive. LUNGS AND PLEURA: Intubated. Predominantly upper lobe emphysema. Mild reticular opacities in the lung bases. Linear opacity in the left lung base likely represents atelectasis or scarring. No pleural effusions. Several scattered micronodules are present, several of which are calcified and likely related to prior granulomatous disease. The largest noncalcified lung nodule measures 3 mm in the right upper lobe. There is new bilateral lower lobe consolidation and volume loss. MEDIASTINUM AND HILA: Calcified right hilar and mediastinal lymph nodes are likely due to prior granulomatous disease. Other small mediastinal and hilar lymph nodes are present, but no significantly enlarged mediastinal or hilar node. Aortic and coronary atherosclerotic calcifications are present. Cardiomegaly. The orientation of the heart within the thorax is abnormal with posterior displacement of the ventricles. The pericardium is seen at the level of the right AV groove, but elsewhere, pericardium is not clearly apparent. This raises the possibility of partial absence of the pericardium, which could explain the abnormal orientation of the heart. CHEST WALL: Degenerative changes affect the thoracic spine.ABDOMEN: LIVER, BILIARY TRACT: There is a poorly defined hepatic mass with intrahepatic biliary dilatation in the left lobe. Multiple new hypodensities have appeared throughout the liver since the prior MRI exam. The dominant left lobe mass in hepatic segment 2/3 is larger and now measures 7 x 7 cm, associated with intrahepatic biliary dilation in left lobe; findings most consistent with cholangiocarcinoma (series 4, image 79). The fat layer between this exophytic mass and the pancreas appears preserved. The mass occludes the left bile duct approximately 1 cm from confluence, however, the confluence itself appears unaffected. Left hepatic and portal veins are obliterated by mass. The middle hepatic vein passes immediately lateral to mass but appears unaffected. No extrahepatic biliary ductal dilation. New metastasis in the posterior inferior right hepatic lobe measures more than 4 cm in diameter (image 93 of series 4). The metastases have indistinct margins. The new smaller hepatic hypodensities have better defined borders and may represent metastases vs. septic emboli, although metastases are more likely. There is an accessory left hepatic artery arising from the left gastric artery. The left gastric artery arises directly from the aorta adjacent to the celiac trunk (series 17, image 57). SPLEEN: No significant abnormality noted.PANCREAS: Pancreatic calcification, probably from prior pancreatitis.ADRENAL GLANDS: No significant abnormality noted.KIDNEYS, URETERS: Bilateral renal cysts. No hydronephrosis.RETROPERITONEUM, LYMPH NODES: There is diffuse retroperitlymphadenopathy. BOWEL, MESENTERY: No significant abnormality noted.BONES, SOFT TISSUES: No significant abnormality noted.OTHER: New moderate ascites. IVC filter is in place. PELVIS:PROSTATE, SEMINAL VESICLES: No significant abnormality noted.BLADDER: Foley catheter in a decompressed urinary bladder. There is an reservoir for the patient's penile prosthesis in the expected position adjacent to the bladder.LYMPH NODES: No significant abnormality notedBOWEL, MESENTERY: A rectal tube is in expected position.BONES, SOFT TISSUES: Degenerative changes of the lumbosacral spine and pelvis.OTHER: Moderate ascites. Probable carcinomatosis of the mesentery.
Findings consistent with left liver lobe cholangiocarcinoma. Dominant left lobe mass is larger since 10/12/2011, and multiple new hepatic hypodensities have appeared. New hepatic metastases. New moderate ascites. New bilateral lower lobe consolidation / volume loss.New diffuse omental density suggests carcinomatosis. 