Alcoholic Hepatitis Mimicking Hepatocellular Carcinoma

Introduction: Painless jaundice with liver mass on imaging raises the possibility of malignancy especially in a background of cirrhosis. Case Description/Methods: A 52-year-old man with a history of alcohol abuse, obesity presented to the hospital with jaundice for 2 weeks. He endorsed drinking six-packs of beer daily for 20 years with alcohol consumption till onset of jaundice. He denied abdominal pain, distention, change in stool color, new medications, or use of herbal supplement. No prior known liver disease. His blood work was significant for a total bilirubin of 27.4 mg/dl (previously 1.53 mg/dl), direct bilirubin of 23.9 mg/dl, Alkaline phosphatase of 198 U/L (Normal:35-144U/L), AST of 138 U/L (Normal:10-35 U/L), ALT of 66 U/L (Normal:9-44 U/L). Sodium of 132 mmol/L (Normal:135-145 mmol/L), Creatinine of 1.30 mg/dl (Baseline 0.85), Prothrombin time of 16 sec (reference 11.7-14.7), INR of 1.3 (reference 0.9-1.2). CBC was unremarkable except for mild thrombocytopenia. CT scan with contrast showed cirrhosis and splenomegaly with a 5cm left hepatic lobe mass without biliary ductal dilation. Abdominal Ultrasound also showed an isoechoic 5.2 x 4.2 x 3.9 cm mass. MRI liver done to further characterized liver lesion showed cirrhosis and a 4.1 x 4.8 cm right hepatic dome mass with scattered smaller lesions in the left and right lobe with contrast washout suggestive of multifocal hepatocellular carcinoma versus vascular metastases. Portal vein and hepatic veins were patent Alpha fetoprotein, PSA and CEA were normal with elevated CA 19-9 to 106 (Normal 0- 37 U/ml). Extensive cirrhosis etiology workup was negative. He underwent IR liver biopsy with findings of steatohepatitis, extensive pericellular fibrosis, with changes suggestive of hepatic outflow obstruction but negative for malignancy. Liver biopsy was complicated by subcapsular hematoma. He completed a 28-day steroid course for severe alcoholic hepatitis with favorable response. Follow up imaging done at 3 months in setting of alcohol abstinence showed no focal liver lesions. Discussion: Regenerative nodules can arise in patient with alcoholic hepatitis, especially with underlying cirrhosis, mimicking hepatocellular carcinoma. Regenerative nodules should be considered as a differential diagnosis of liver masses especially with normal alpha-fetoprotein. Complete resolution of these nodules can be seen with alcohol abstinence. Short interval repeat imaging after a period of alcohol abstinence might reduce the need for liver biopsy.Figure 1.: A: CT scan of the abdomen showing left hepatic lobe mass B and C: H&E stains of liver nodule showing steatohepatitis, bile stasis and pericellular fibrosis D. Trichrome stain of liver nodule biopsy showing pericellular fibrosis.