1. Case 1 M/72 C.C : hematemesis P.Hx. : N-S 12119993

2. Endoscopic Variceal Ligation
2016/1/3
Eso: Inc. 38cm에 vessel engorgement 부위에서  spurting bleeding 관찰되어 시야가 확보가 되지 않을 정도로 출혈이 많았으며 nipple sign 보여 EVL 시행함.(검사 중 1.5리터 정도 hematemesis하여 teripin 2A 투여함)

3. Liver CT, 2016/1/3

4. Abdomen US

5. Differential Diagnosis
Multifocal hypovascular HCC
Diffuse hepatic metastasis
Multiple infarcted nodules ; resemble ~
Multifocal hypovascular HCC
Diffuse metastasis
Von Meyenberg complex
Multiple dysplastic nodules
그러나 peripheral enhanced nodule rim ; 위의 질환들 배제 가능

6. Differential Diagnosis
Multifocal hypovascular HCC
Iso- or hypoattenuating on arterial phase imaging
Similarly, on portal venous phase CT, often appears either iso-or hypo

7. Differential Diagnosis
Multifocal hypovascular HCC
Diffuse hepatic metastasis
Most metastases are revealed as low- or isoattenuating masses on CT
Most metastases are hypovascular, complete ring E+(arterial), centripetal E+
Central low attenuating : result of necrosis or cystic change
Depending on lesion size, margins tend to be irregular, but well defined

8. Abdomen MR
T1WI
T2WI

9. Abdomen MR
Arterial
Portal
Delayed
Hepatobiliary

10. Abdomen MR
B=50
B=400
ADC
B=800

11. PET-CT

12. Liver CT, 2016/4/21

13. Infarcted Regenerative Nodules
Diagnosis
Infarcted Regenerative Nodules

14. Infarcted RNs in Cirrhosis
Infarcted regenerative nodules (anoxic pseudolobular necrosis)
Ischemic coagulative necrosis
1957, Edemondson et al.
Infarcted RNs have been observed at autopsy in pt with LC
Okuda et al.
Described similar liver necrosis at autopsy in pts c LC or liver carcinoma
Most of whom died of shock from GI hemorrhage or rupture of tumor
Sudden reductions in the portal and arterial circulation after blood loss or shock induce an ischemic state
Because RNs are mainly supplied by portal venous flow
Infarcted RN could easily develop given reduced PV flow

15. Infarcted RNs in Cirrhosis
Histopathologic Findings
Single or multiple forms
Multiple infarcted nodules coalesced to form single necrotic area
Several necrotic nodules were seen in close proximity to each other
Sizes of the focal lesions 0.5-2cm, superficial and deep areas
Central core of amorphous eosinophilic material
Remnants of necrotic hepatocytes and other cellular elements
Early fibroplasia could be seen peripheral to the macrophages

16. Infarcted RNs in Cirrhosis
US Findings
Hypo/iso/hyper echogenic nodules

17. Infarcted RNs in Cirrhosis
CT Findings
NECT : hypoattenuation lesions compared with liver parenchyma
CECT : Oval nodular lesions measuring cm
Central (isoattenuating) and peripheral (hypoattenuating )
Homogeneous hypo (arterial), center hypo & peripheral E+ (portal venous)
Heterogeneous patchy E+
Fig. 1.—Infarcted regenerative nodules in 55-year-old man with prior episode of bleeding from esophageal varices and gastric ulcer. A, Unenhanced CT scan shows oval hypoattenuated nodular lesion (arrow) that measures 1.5 cm in diameter in right lobe of liver. Note abundant ascites and changes of cirrhosis evident in hepatic morphology.
B, Arterial phase helical CT scan obtained at same level as A shows central and peripheral portions of lesion (arrow) as enhancing to approximately the same degree as liver parenchyma. Note that remaining lesion is mainly hypoattenuating.
C, Portal venous phase helical CT scan obtained at same level as A and B shows central and peripheral enhancement equal to that of liver parenchyma and encompassing larger proportion of lesion (arrow). Hypoattenuating portion of lesion occupies smaller component than that in A and B. (Fig. 1 continues on next page)

18. Infarcted RNs in Cirrhosis
CT Findings
NECT : hypoattenuation lesions compared with liver parenchyma
CECT : Oval nodular lesions measuring cm
Central (isoattenuating) and peripheral (hypoattenuating )
Homogeneous hypo (arterial), center hypo & peripheral E+ (portal venous)
Heterogeneous patchy E+
Fig. 2.—Infarcted regenerative nodules in 47-year-old man with prior episode of gastrointestinal bleeding from esophageal varicesA, Unenhanced CT scan shows oval 1-cm lesion (arrow) hypoattenuating to adjacent liver parenchyma in lateral segment of liver. B, Arterial phase helical CT scan obtained at same level as A shows lesion (arrow) to be predominately hypoattenuating compared with surrounding liver parenchyma. C, Portal venous phase helical CT scan obtained at same level as A and B shows central portion of lesion (arrow) remaining hypoattenuating; however, peripheral portion has enhanced to similar degree as adjacent liver parenchyma.

19. Infarcted RNs in Cirrhosis
CT Findings
NECT : hypoattenuation lesions compared with liver parenchyma
CECT : Oval nodular lesions measuring cm
Central (isoattenuating) and peripheral (hypoattenuating )
Homogeneous hypo (arterial), center hypo & peripheral E+ (portal venous)
Heterogeneous patchy E+
Fig. 3.—Infarcted regenerative nodules in 67-year-old man with prior episode of massive bleeding from esophageal varices. A, Unenhanced CT scan shows large hypoattenuated lesion in posterior segment of liver. Note how lesion has bulging contour (arrows). B, Conventional contrast-enhanced CT scan shows patchy enhancement of lesion with zones of enhancement equal to that of liver parenchyma; however, large regions of hypoattenuation persist. C, Conventional contrast-enhanced CT scan obtained at higher level than A and B shows upper portion of large lesion (arrow) with heterogeneous enhancement and another smaller lesion (arrowheads), findings that mimic those of neoplastic disease.

20. Infarcted RNs in Cirrhosis
MR Findings
T2WI : iso/moderate high SI, T1WI : iso/low SI T1&T2WI : high SI
Dynamic MR images
Arterial and portal venous phase : hypointense to liver parenchyma
Delayed T1C+
Central portion : enhancement, same degree as surrouding parenchyma
- central retained viable tissues and revascularization seen histologically

21. F/33, liver cirrhosis, AFP 2ng/mL
Abdomen Imaging 2004;29:
F/33, liver cirrhosis, AFP 2ng/mL
control of ascites and hepatic encephalopathy
hypotension d/t septic shock (110/80 →80/44mmHg) , no bleeding (Hb 14.2)
Fig. 1. A 33-year-old woman with advanced liver cirrhosis who had an episode of severe hypotensive crisis.
A Delayed phase CT before the episode of acute hypotension shows innumerable, ill-defined, low-attenuating nodules representing regenerative nodules. The liver is in a shrunken state and its surface is nodular due to severe cirrhosis.
B Delayed phase CT scan after the episode of hypotension shows multiple, well-defined, low-attenuating nodules surrounded by a
peripheral hyperattenuating rim. The nodules are scattered in the right, left, and caudate lobes, especially along the periphery of the liver. The size of these newly developed lowattenuating nodules is the same as that of regenerative nodules in the remainder of the liver.
C T2 weighted MR image shows several nodules of high signal intensity. The CT and MR images are markedly different in terms of the number of nodules depicted, with only a few of the infarcted regenerative nodules depicted on MR images.
D Photograph of a segment of the explanted liver shows multiple, small and medium-size, light-colored nodules representing coagulative necrosis of the regenerative nodules (arrows). The dark nodules are living regenerative nodules.

22. Reference Case 1 The Korean Journal of Hepatology 2008;14:387-393
AJR 2000;174:
AJR 2000;175:
Abdomen Imaging 2004;29:
Journal of Hepatology 40 (2004) 1040