Subacute Abdominal Pain in a Patient With Chronic Liver Disease and Hepatocellular Carcinoma.

A66-year-oldwomanwith chronic hepatitisBinfectionandhepatocellular carcinoma(HCC) presented with subacute epigastric pain. Three years prior, she was diagnosed with a solitaryHCCand underwent surgical resection with curative intent. Pathology revealed poorly differentiated HCC, 16cmin largest dimension, with large vein involvement(T3bNXM0, R0 resection). The patient underwent expectant observation. One and a half years prior to the current presentation, laboratory results revealed an elevated a-fetoprotein (AFP), andcrosssectionalimagingrevealed multiple lungnodules consistent withmetastases. Shewas treated with nivolumab every other week and attained a biochemical (baseline, 212.2 ng/dL; best response, 3.3 ng/dL) and radiographic complete response. In the current presentation, the patient reported nonradiating epigastric pain of moderate intensity for 1month. Associated symptomsincluded nausea, anorexia, andwater brash without emesis. Review of systems was positive for unchanged chronic abdominal bloating and negative for other constitutional or gastrointestinal symptoms. Laboratory results, including liver function tests, amylase, lipase, andAFP, were within normal limits, and hepatitisBvirus polymerase chain reactionwas undetectable. Computed tomography with multiphasic liver protocol showed new enlarged mesenteric nodes and diffuse thickening of the gastric body (Figure, A). Esophagogastroduodenoscopy (EGD) identified diffuse inflammation and ulcerations in the gastric body and antrum (Figure, B). Biopsy specimens showed chronic and active mixed inflammatory infiltrate, including intraepithelial lymphocytosis (Figure, C). No overt viral cytopathic effects were observed, and immunostaining results for Helicobacter pylori, cytomegalovirus, and adenovirus were negative.