Close follow-up of patients with liver cirrhosis has led to increased detection of hepatocellular carcinoma (HCC) at an early stage, especially with magnetic resonance imaging (MRI) innovations. We report the case of a 70-year-old man, with a recent history of liver cirrhosis due to chronic hepatitis C virus (HCV) complicated by hepatocellular carcinoma (HCC), and for whom trans-arterial chemoembolization (TACE) was planned, as the patient was assigned Child B7 at admission. Angiography performed during the first TACE cycle shows not only the \"tumor blush\" corresponding to previously detected HCC but also an additional small foci of HCC uptake seen within a large dysplastic nodule giving the appearance of \"nodule-within-nodule.\" Early detection of hepatocellular carcinoma improves prognosis. Hence, it is essential to be aware of all early aspects of HCC, including the nodule-within-nodule appearance on cross-sectional imaging, and also in angiography, as in this case.

Hereditary tyrosinemia type 1 (HT1) is an autosomal recessive disorder caused by a defect in fumarylacetoacetate hydroxylase (FAH) encoded by the FAH gene. Patients with HT1 disorder present with increased blood tyrosine, succinyl acetoacetate, and succinyl acetone levels, and develop clinical manifestations including liver failure, kidney tubular dysfunction, growth failure, rickets, pseudo-porphyric crises, and hepatocellular carcinoma. We encountered two siblings with HT1. Among the siblings, the elder brother developed acute liver failure with coagulopathy at the age of 2 months and was rescued by liver transplantation (LT) following combination therapy with continuous hemodiafiltration and plasma exchange. The younger sister was followed up from the prenatal period for signs of HT1 due to prior history of the condition in her sibling. She was initially considered a carrier of HT1 owing to the lack of overt signs of the disease and negative urine screening for succinyl acetone (SA). She was eventually diagnosed with HT1 because of liver disorder at 9 months of age, associated with a positive urine SA result. Her disease state was controlled by treatment with nitisinone (NTBC). DNA analysis of both siblings identified heterozygous status for a previously reported FAH pathogenic allele (c.782C > T) and a novel likely pathogenic variant (c.688C.G). The siblings have stable lives with no developmental delay or impaired growth. NTBC treatment is effective in preventing the progression of liver and kidney diseases. However, even in cases treated without LT, clinicians should follow up the clinical outcomes over long term, as patients may require LT when developing complications, such as hepatocellular carcinoma.

Contrast-enhanced ultrasound (CEUS) is one of the important imaging modalities for diagnosis of hepatocellular carcinoma (HCC). Sonovue and Sonazoid are the third-generation of ultrasound contrast agents that have been commercialized and widely used in clinical applications. This study introduces the imaging differences between these two agents in vascular phases for the first time. A 54-year-old man clinical suspected liver cancer. He had chronic hepatitis B for more than 20 years. The result of alpha-fetoprotein was 36.45μg/L (normal< 20μg/L). The imaging pattern of CEUS with Sonovue was \"fast-in and fast-out\" performance, while the pattern of \"fast-out\" was absent after portal phase with Sonazoid, even in Kupffer phase. The lesion was diagnosed as lipid-rich HCC by contrast-enhanced MRI. After liver resection, pathology revealed that it was hepatocellular carcinoma contained poor-differentiated steatohepatitis subtype and moderate-differentiated microtrabecular subtype. The imaging difference mainly existed in the part of steatohepatitis subtype. Steatohepatitis subtype HCC can be showed as \"fast-in and no wash-out\" characteristic in Sonazoid CEUS. Though the mechanism remains not fully clarified, this different enhancing pattern may provide a potential for the supplement of the guidelines and differential of steatohepatitis subtype HCC.

Video 1Peroral cholangioscopy showed a 20-mm-diameter, stalked, floating, round mass in the hilar region. The surface of the tumor was covered with white fur, and the tumor tissue was partially exposed in a map-like pattern. The mass was penetrable even with a guidewire, and it bled easily. Biopsies were performed using biopsy forceps, and the tumor bled easily even with biopsy.

We describe the case of a 32-year-old man who developed a liver neoplasm due to previous Fontan surgery (FS) for a single ventricle anomaly and situs viscerum inversus. He was admitted to our hospital for suspected hepatocellular carcinoma during an Ultrasound (US) follow up. Computed tomography (CT) showed features of chronic liver disease and 7 cm hepatic nodule with arterial enhancement. Laboratory analyses documented preserved liver function and increased levels of alpha-fetoprotein. Trans-arterial-chemoembolization (TACE) was performed obtaining complete necrosis at 4 weeks of follow up and significant reduction of alpha-fetoprotein. The patient is currently in follow-up, being evaluated for further treatments and/or combined liver-heart transplantation. TACE is a therapeutic option for the treatment of patients with unresectable hepatocellular carcinoma (HCC) and with severe heart disease, like those submitted to FS and with also other vascular abnormalities like those correlated to situs viscerum inversus.

Liver rupture in pregnancy is an acute condition with significant risk to the mother and fetus. It is known to occur with tumors such as hepatic adenoma, infective causes such as abscess, granulomatous diseases, and parasitic infections, and rarely spontaneously. Most of these conditions have overlapping clinicoradiological findings, almost always requiring histopathological confirmation. We report a case of a ruptured hepatic lesion, with an unusual diagnosis of Bartonella henselae infection causing cat-scratch disease, in a 24-year-old pregnant lady.

Alagille syndrome (AS) is an autosomal dominant multisystem disorder which can lead to hepatopathy and the development of focal hepatic lesions. The majority of the hepatic lesions are benign, including regenerative nodules, focal hyperplasia, and adenoma. Hepatocellular carcinoma (HCC) is extremely rare in AS, with very few cases reported in the literature. A 38-year-old man complaining of acute right upper quadrant pain with long-standing diagnosis of Alagille syndrome. On imaging, the patient had a large hepatic mass in the right lobe, with arterial hyperenhancement, washout appearance, and areas of internal hemorrhage. The patient underwent a right hepatectomy and histopathology demonstrated HCC. The patient passed away 3 months after the surgery due to infectious complications. HCC is a rare complication of AS, although rare, it should be considered. This case also emphasizes the need of HCC screening in patients with AS in order to allow an early diagnosis and treatment, which can improve patients\' outcome.

Mammalian target of rapamycin inhibitors (mTORis) are immunosuppression agents that are commonly used in solid organ transplantation. Available mTORis include sirolimus and everolimus. Interstitial lung disease (ILD) is an uncommon side effect of mTORis in liver transplantation. A high index of suspicion is needed, and timely intervention can reverse the disease. We present a case of sirolimus-induced ILD that improved after discontinuation of sirolimus.

Primary sarcomatous hepatocellular carcinoma (PSHCC) is a rare and aggressive variety of hepatocellular carcinoma (HCC). The recent evidence suggests that anticancer therapy promotes the dedifferentiation of the carcinomatous component and is largely responsible for this aggressive variant of HCC. However, in the absence of any anticancer therapy, occurrence of PSHCC is extremely rare. Herein, we present a rare case report of a 65 year old male patient, with a hepatitis B positive status, presenting with PSHCC without any history of anticancer therapy. Detailed immunohistochemical evaluation of the tumor was performed with comparison of morphological and immunohistochemical features of the sarcomatous and carcinomatous components. This appears to be the first documented case of PSHCC from India, to the best of our knowledge.

OBJECTIVE: NAFLD has today emerged as the leading cause of liver disorder. There is scanty data on risk factors associated with NAFLD emanating from India. The present study was conducted to identify the risk factors associated with NAFLD.
METHODS: 464 consecutive NAFLD patients and 181 control patients were subjected to detailed questionnaire regarding their lifestyle and dietary risk factors. Anthropometric measurements were obtained and biochemical assays were done. Comparison of different variables was made between NAFLD patients and controls using principal component analysis (PCA).
RESULTS: NAFLD patients had higher BMI [26.25 ± 3.80 vs 21.46 ± 3.08 kg/m(2), P = 0.000], waist-hip ratio [0.96 ± 0.12 vs 0.90 ± 0.08, P = 0.000] and waist-height ratio [0.57 ± 0.09 vs 0.50 ± 0.06, P = 0.000] compared to controls. Fasting blood sugar [101.88 ± 31.57 vs 90.87 ± 10.74 mg/dl] and triglyceride levels [196.16 ± 102.66 vs 133.20 ± 58.37 mg/dl] were significantly higher in NAFLD group. HOMA-IR was also higher in NAFLD group [2.53 ± 2.57 vs 1.16 ± 0.58, P = 0.000]. Majority (90.2%) of NAFLD patients were sedentary. Family history of metabolic syndrome (MS) was positively correlated with NAFLD. Dietary risk factors associated with NAFLD were non-vegetarian diet [35% vs 23%, P = 0.002], fried food [35% vs 9%, P = 0.000], spicy foods [51% vs 15%, P = 0.001] and tea [55% vs 39%, P = 0.001]. Diabetes, hypertension, snoring and sleep apnoea syndrome were common factors in NAFLD. On multivariate PCA, waist/height ratio and BMI were significantly higher in the NAFLD patients.
CONCLUSIONS: The risk factors associated with NAFLD are sedentary lifestyle, obesity family history of MS, consumption of meat/fish, spicy foods, fried foods and tea. Other risk factors associated with NAFLD included snoring and MS.