Pitfall: A pseudo tumor within the left liver lobe presenting with abdominal pain, jaundice and severe weight loss

A 51 year old male patient with a history of chronic alcohol consumption an d recurrent pancreatitis was referred to our hospital with jaundice, epigas tric pain, severe diarrhoea and weight loss of 28 kg within the last 12 mon ths. A CT scan of the abdomen 4 months before admission had shown a pancrea titis with free fluid around the corpus and tail of the pancreas as well as dilated intrahepatic bile ducts and a cavernous transformation of the port al vein. Moreover, a tumor (3.5 x 3.0 x 3.6 cm) with irregular contrast enh ancement was seen within the left liver lobe. The patient was referred to u s for further evaluation and treatment. The initial B-Mode sonogram reveale d a bull's eye like well defined lesion (8.1 x 7.5 x 7.0 cm) within the lef t liver lobe, consistent with a tumour or abscess. Prior to a diagnostic ne edle biopsy a PTCD was performed in this case presenting with dilated intra hepatic bile ducts and having a history of Bill-roth II operation. An addit ional colour coded Duplex Doppler ultrasonography demonstrated a visceral a rtery aneurysm and prevented us from performing the diagnostic puncture. Th e aneurysm was assumed to originate from a variant or a branch of the left hepatic artery. Angiography revealed a pseudoaneurysm of the pancreaticoduo denal artery and coil embolization was performed because of the increasing size and the risk of a bleeding complication. Postinterventional colour dup lex ultrasound measurement showed no blood flow within the aneurysm. Retros pectively, the pseudoaneurysm must have led to a compression of the common bile duct, since the patient did not develop cholestasis after embolization and removal of the PTCD. Thus, a pseudoaneurysm of the pancreaticoduodenal artery must be included in the differential diagnosis of liver tumours in patients with chronic pancreatitis, despite its unusual localization near t he liver. Therefore, we suggest that colour coded ultrasonography should be applied to any unclear, bull's eye like lesion, even though this method al one cannot exactly determine the origin of the pseudoaneurysm. Intervention al angiography remains the gold standard for the diagnosis and therapy of v isceral artery aneurysm.