Pneumatosis Cystoides Intestinalis in a Patient with Dermatomyositis: A Case Report and Review of the Literature / 대한내과학회지

Pneumatosis cystoides intestinalis (PCI) is a rare disease with intramural gas formation in the gastrointestinal tract. The causes of PCI are various, and are commonly associated with collagen vascular disease. We present a case of a 48-year-old female with dermatomyositis (DM) who also developed PCI. Her risk of PCI may have been increased by multiple factors such as gender, DM itself, and medications including corticosteroids, methotrexate, and azathioprine. While the cause of, and risk factors for PCI in DM patients are not well known on a global scale, outcomes range from benign to life threatening. Therefore, we present a case study and review the literature to identify candidate risk factors for PCI.

Evaluation of Small Bowel Obstruction Using Multidetector Computed Tomography (MDCT)

Small bowel obstruction is a relatively common clinical condition and its diagnosis is based on the clinical signs, the patient's history and the radiologic findings. For a patient with suspected small bowel obstruction, it is essential to determine the site, location and cause of obstruction for the appropriate management. Because of the poor accuracy of plain radiography, computed tomography (CT) now has an essential role to diagnose bowel obstruction. With the recent evolution of conventional CT into multi-detector computed tomography (MDCT), it is possible to obtain cross sectional images with high spatial resolution and different post-processes can be done, such as obtaining the volume rendering (VR), maximum intensity projection (MIP), or multiplanar reformatted (MPR) images from the volume data. In this article, we illustrate and discuss the utility of the multiplanar images of MDCT for diagnosing the sites, causes and complications of small bowel obstruction.

Diagnosis of Iatrogenic Femoropopliteal bypass Graft Entrapment Syndrome by MDCT: A Case Report

Popliteal artery entrapment syndrome is a well-known congenital condition causing limb ischemia. A similar entity caused by entrapment of a femoropopliteal bypass graft by the muscle and tendons around the knee has also been described. Ultrasonography or MR imaging is considered as a choice of a noninvasive modality for this condition, but there are some limitations. We report a case of iatrogenic entrapment of femoropopliteal bypass graft that was confirmed by multidetector row computed tomography (MDCT).

Pneumatosis Cystoides Intestinalis in Patients with Antinuclear Antibody Negative Systemic Lupus Erythematosus and Dermatomyositis: Report of Two Cases

Pneumatosis cystoides intestinalis (PCI) occurring in association with collagen vascular disease is an unusual combination that presents with intramural gas in the gastrointestinal tract. We report two cases of PCI, one with antinuclear antibody (ANA) negative SLE and the other with dermatomyositis, with a review of the relevant literature.

Extramedullary Plasmacytoma of Small Bowel Mesentery in Associated with Cecal Cancer: A Case Report

Extramedullary plasmacytoma is a rare disease that is histopathologically defined as a solitary tumor composed of a monoclonal proliferation of cells with plasmacytic differentiation in an extramedullary site. Most of these tumors occur in the submucosa of the upper aerodigestive tract, and they rarely occur in the small bowel mesentery. We report here on a case of extramedullary plasmacytoma of the small bowel mesentery that was in association with a cecal cancer. Abdominal ultrasound and CT revealed a lobulated soft tissue mass with a cystic portion and peripheral calcification. In this case, the preoperative radiological diagnosis was difficult due to accompanying cecal cancer.

Feasibility of Saline Infusion on the Liver Surface during Radiofrequency Ablation of Subcapsular Hepatic Tumor: An Experimental Study

PURPOSE: The purpose of the study was to evaluate the feasibility of infusion of normal saline onto the surface of the liver capsule for minimizing thermal injury of the adjacent organs during radiofrequency ablation of subcapsular hepatic tumor in an ex-vivo porcine model. MATERIALS AND METHODS: We used porcine small bowel with it's serosal surface spread onto the porcine liver as an experiment model. The puncturing electrode was inserted into a 6 Fr introducer sheath, and the introducer sheath was connected to the infusion pump for creating a saline flow over the liver surface . A total of 15 ablations were divided into the control group (n=5), intermittent saline infusion group (n=5) and continuous saline infusion (n=5) group. The ablations were done during 3 minutes, and the infusion was set at 2 ml/min and stopped every 30 seconds in the intermittent saline infusion group. After the ablation, we measured the size of the ablated lesion on the surface of bowel and liver, and we also measured the depth of hepatic lesion. RESULTS: Ablated areas of bowel and liver surface in the control group, intermittent saline infusion group and continuous infusion group were 210.7+/-89.1 mm2, 74.6+/-27.2 mm2 and 35.8+/-43.4 mm2, respectively, and 312.6+/-73.6 mm2, 228.4+/-110.5 mm2, and 80.9+/-55.1 mm2, respectively. In contrast to the broad base of the ablated area on the surface of the liver in the control group, the shapes of the lesions became narrower approaching to the liver surface in all cases of the continuous saline infusion group, and the shapes of the lesions were broad based in 3 cases and narrow based in 2 cases of the intermittent saline infusion group. CONCLUSION: Continuous infusion of normal saline onto the surface of the liver during radiofrequency ablation of subcapsular hepatic tumor is a feasible method for minimizing thermal injury of the adjacent organs. Further exploration of the optimal parameters or techniques to maximize the hepatic ablation and simultaneously to minimize the thermal injury of adjacent organs is required.

An Experimental Study of Simultaneous Ablation with Dual Probes in Radiofrequency Thermal Ablation

PURPOSE: To determine the differences between sequential ablation with a single probe and simultaneous ablation with dual probes. MATERIALS AND METHODS : Using two 14-gauge expandable probes (nine internal prongs with 4-cm deployment), radiofrequency was applied sequentially (n=8) or simultaneously (n=8) to ten ex-vivo cow livers. Before starting ablation, two RF probes with an inter-probe space of 2 cm (n=8) or 3 cm (n=8) were inserted. In the sequential group, switching the connecting cable to an RF generator permitted ablation with the second probe just after ablation with the first probe had finished. In the simultaneous group, single ablation was performed only after connecting the shafts of both RF probes using a connection device. Each ablation lasted 7 minutes at a target temperature of 105-110 degrees C. The size and shape of the ablated area, and total ablation time were then compared between the two groups. RESULTS: With 2-cm spacing, the group, mean length and overlapping width of ablated lesions were, respectively, 5.20 and 5.05 cm in the sequential group (n=4), and 5.81 and 5.65 cm in the simultaneous group (n=4). With 3-cm spacing, the corresponding figures were 4.99 and 5.60 cm in the sequential group (n=4), and 6.04 and 6.78 cm in the simultaneous group (n=4). With 2-cm spacing, the mean depth of the proximal waist was 0.58 cm in the sequential (group and 0.28 cm in the simultaneous group, while with 3-cm spacing, the corresponding figures were 1.65 and 1.48 cm. In neither group was there a distal waist. Mean total ablation time was 23.4 minutes in the sequential group and 14 minutes in the simultaneous group. CONCLUSION: In terms of ablation size and ablation time, simultaneous radiofrequency ablation with dual probes is superior to sequential ablation with a single probe. A simultaneous approach will enable an operator to overcome difficulty in probe repositioning during overlapping ablations, resulting in complete ablation with a successful safety margin.

Transluminal Radio-Frequency Thermal Ablation Using a Stent-Type Electrode: an Experimental Study

PURPOSE: To assess the feasibility of transluminal radiofrequency thermal ablation using a stent-type electrode and to determine, by means of in-vitro and in-vivo animal studies, the appropriate parameters. MATERIALS AND METHODS: In vitro: The radiofrequency electrode used was a self-expandable nitinol stent with 1cm insulated ends. A stent was placed in the portal vein of bovine liver, and ablations at target temperatures of 70, 80, 90, and 100degrees C were performed. Ablated sizes were measured longitudinally. In vivo: Four mongrel dogs were anesthetized, and a stent was inserted in the common bile duct under fluoroscopic guidance through an ultrasound-guided gall bladder puncture site. The ablation temperature was set at 80 degrees C, and each dog underwent proximal and distal esophageal ablations lasting 12 minutes. They were sacrificed immediately. RESULTS: In-vitro: Ablated sizes showed significant correlation with target temperatures (r>0.04; p<0.05). Although most lesions were fusiform, dumbbell-shaped lesions with central thinning were found in two cases in the 70degrees C group. In all cases in the 70 degrees C and 80 degrees C group, the length of the insulated segment was less than 1 cm. In-vivo: At microscopy, tissues at the center of the biliary stent showed more prominent pathological change than those at the periphery while those remote from the stent showed minimal or no change. In esophageal ablations, the mean highest temperature was 48.6 degrees C. Microscopy demonstrated the destruction and shedding of mucosa, edema, and coagulation necrosis of submucosa, but in muscle layers no abnormalities were apparent. CONCLUSION: Transluminal radio-frequency thermal ablation using a stent-type electrode may be useful for elongating patency. The appropriate target temperature for biliary ablation is 80 degrees C.

CT Spectrum of Transient Peritumoral Hyperemia after Radiofrequency Thermal Ablation of Hepatic Tumors

PURPOSE: To determine the incidence and pattern of peritumoral hyperemia at CT after radiofrequency thermal ablation of hepatic tumors, as well as its correlation with local marginal recurrence. MATERIALS AND METHODS: Forty-five tumor nodules in 28 patients with hepatocellular carcinoma (n=34) or metastasis (n=11) were treated by RF thermal ablation. Serial follow-up contrast- enhanced CT scans were reviewed by three radiologists for 1) the presence, 2) the morphological characteristics [circumferential, THAD (transient hepatic attenuation difference), nodular form], and 3) the temporal course (acute, persistent, delayed onset pattern) of peritumoral hyperemia after RF thermal ablation. These findings were correlated with the frequency of recurrence at the margin of the treated tumors. RESULTS: The frequency of acute hyperemia observed on immediate follow-up CT scans after RF ablation was 71% (32/45). There was the local recurrence in nine of 32 tumors (28%) with hyperemia and in one of 13 (8%) without hyperemia (p>0.05). Among 32 tumors, the circumferential form was observed in 22 (69%); the THAD form in eight (25%); and the nodular form in two (6%). Marginal recurrence was noted in five of 22 tumors circumferential tumors (23%), in three of eight (38%) with the THAD form, and in one of two (50%) which were nodular. Among 32 nodules, an acute transient pattern was noted in 21 (66%), a persistent pattern in nine (28%), and a nodular pattern in two (6%). There was marginal recurrence in two (10%) of 21 tumors with acute transient hyperemia, in six (67%) of nine with persistent hyperemia, and in both tumors with delayed-onset hyperemia. There was significant correlation between the pattern of persistent/delayed-onset hyperemia and marginal tumor recurrence of (p=0.001). CONCLUSION: Although peritumoral hyperemia after RF thermal ablation therapy is a frequent transient finding at follow-up imaging studies, its temporal pattern may help detect early marginal tumor recurrence.

The Factors Related to Local Recurrence after Radiofrequency Thermal Ablation of Hepatic Malignancies : Assessment of Spiral CT Findings

PURPOSE: To determine the factors that are related to local recurrence after Radiofrequency thermal ablation (RFTA) of hepatic tumors. MATERIALS AND METHODS: We selected 30 patients with 51 hepatic nodules less than 5 cm in diameter (HCC, n=33; metastasis, n=18) who underwent RF thermal ablation between May 1999 and April 2000. Ablation was defined as 'complete'if immediately post-procedual CT showed that a nodule's margin was completely covered by ablation. Every three months, follow-up CT scans were examined for signs of local recurrence, and a nodule was assessed in terms of its size, the histologic diagnosis, adjacent vessels, perfect ablation (a safety margin of more than 5mm beyond the tumor margin), and whether hyperemia was observed after ablation. Finally, a group in which there was local recurrence (group A, n=15) and another showing no recurrence (group B, n=36) were compared. RESULTS: Mean nodule size in group A and group B was 3.26 and 2.24 cm, respectively. Local recurrence was noted in 7 of 33 HCC nodules (21.2%), and in 8 of 18 (44.4%) which were metastatic. There was recurrence in 9 of 31 nodules with adjacent vessels (29.0%), and in 6 of 20 (30%) without adjacent vessels. In two of 17 perfectly ablated nodules (11.8%) there was local recurrence, but this was observed in 13 of 34 imperfectly ablated nodules (38.2%). Finally, local recurrence was seen in 14 of 36 nodules showing hyperemia (38.9%) but in one of 15 (6.7%) without hyperemia. Using chi-square analysis, it was thus shown that with regard to local recurrence, tumor size, perfect ablation and peritumoral hyperemia were statistically significant factors (p<0.05). CONCLUSION: Local recurrence after RF thermal ablation of hepatic tumors clearly increases in nodules which are larger. The degree to which ablation is perfect, and the presence of peritumoral hyperemia, may be factors related to the local recurrence observed after RFTA.

Sclerosing Stromal Tumor of the Ovary: A Case Report

Sclerosing stromal tumor of the ovary is a rare benign neoplasm, with distinctive clinical and pathologic features. It occurs predominantly in females during the second and third decades of life. Histologically, it is composed of cellular and acellular collagenized areas, and edematous stromal areas, and at ultrasonography and computed tomography is seen as a distinctive mixed solid and cystic mass lesion. We report a case of sclerosing stromal tumor of the ovary in a 15-year-old girl with a history of menorrhagia since menarche. Ultrasonography revealed the tumor as a well-defined, lobulated, heterogenous echogenic pelvic mass, while at CT, a huge pelvic mass 9x9x10 cm in size, was seen. This comprised a well-enhanced internal solid portion, a capsule, septa, and a non-enhanced cystic portion.

Primary Retroperitoneal Synovial Sarcoma: A Case Report

A case of a 36-yr-old woman with retroperitoneal synovial sarcoma is described. Her presenting symptom was epigastric pain that radiating to the back. On radiologic study, bulky retropancreatic soft tissue mass was detected which showed cystic and solid components. At operation, complete resection of the tumor was not possible because of the adhesion to the vena cava and the liver. During the follow-up, extensive tumor recurrence and liver metastasis were revealed. Primary retroperitoneal synovial sarcoma is a very rare malignant tumor with high mortality and recurrence rates. Retroperitoneal synovial sarcoma usually appears as a nonspecific soft tissue mass that do not have specific imaging features differentiating it from other mesenchymal tumors. However general radiologic findings and anatomic location of the tumor may help the diagnosis. In addition, synovial sarcoma should be included in the differential diagnosis of retroperitoneal soft tissue mass detected in young adults.

Radiofrequency Thermal Ablation of Metastatic Liver Tumors: Usefulness of Combined Chemotherapy

PURPOSE: To assess the usefulness of radiofrequency (RF) thermal ablation with combined chemotherapy for the treatment of metastatic liver tumors. MATERIALS AND METHODS: A non-randomized, comparative study was performed in 21 patients with metastatic liver tumors. Inclusion criteria were that these should be less than five in number and less than 6 cm in diameter. Two groups were designed for comparison of the local and remote (new intrahepatic or extrahepatic) tumor control rate (Group A: RF alone, n=11; Group B: RF+combined chemotherapy, n=10). There was no significant difference in age, sex, and mass size between the two groups (p>0.05). All ablations were performed percutaneously with a 50W RF generator and 15G-needle electrode (RITA Medical System Inc.) under US guidance. In group B, six cycles of systemic chemotherapy were performed every month immediately after RF ablation. Follow-up CT scans were obtained within 24 hours of ablation and were compared with the findings of pre-ablation CT scanning. If an ablated lesion covered the mass without any residual enhancing foci, this was defined as complete ablation. Three and six months after ablation, local and remote tumor control rates were compared between the two groups (follow up: range 4 -17 (mean, 10.2) months. RESULTS: In group A, the local tumor control rate was 43.8% (7/16) and 31.2% (5/16) at 3 and 6 months follow-up, respectively, while in group B, the corresponding rates were both 75% (15/20). At three months, the difference in this rate between the two groups was not significantly different (p>0.05), but at 6 months there was significant difference (p<0.05). At 6 months follow-up, the remote tumor control rate for Group A and Group B was 27.3% (3/11) and 80.0% (8/10), respectively, reflecting a significant difference between the two groups (p<0.05). CONCLUSION: In patients with metastatic liver tumor, radiofrequency thermal ablation with combined chemotherapy may be superior to RF thermal ablation alone for both local and remote tumor control.

Radiofrequency Thermal Ablation of Benign Cystic Lesion:An Experimental Pilot Study in a Porcine Gallbladder Model

PURPOSE: To determine whether radiofrequency thermal ablation can be used to treat benign cystic lesions in a porcine gallbladder model. MATERIALS AND METHODS: This experimental study of radiofrequency thermal ablation involved the use of 15 exvivo porcine gallbladders and 15-G expandable needle electrodes. To investigate optimal temperature parame-ters,three groups of five were designated according to target temperature: Group A: 70 degrees C; Group B: 80 degrees C; Group C: 90 degrees C. After the target temperature was reached, ablation lasted for one minute. Gallbladder width, height and length were measured before and after ablation, and the estimated volume reduction ratios of the three groups were compared. Whether adjacent liver parenchyma around the gallbladder fossa was ablated by heat conducted from hot bile was also determined, and the thickness of the ablated area of the liver was measured. RESULTS: The volume reduction ratio in Group A, B and C was 42.7%, 41.7% and 42.9%, respectively (p>.05). In all 15 cases, gallbladder walls lost their transparency and elasticity at about 70 degrees C. In nine of ten cases in Groups B and C, the hepatic capsule around the gallbladder fossa was retracted at about 80 degrees C. The mean thickness of liver parenchymal damage adjacent to the gallbladder was 5.4 mm in Group B and 9.8 mm in Group C. In Group A livers, only one case showed minimal gradual parenchymal change. Microscopically, all three groups showed complete coagulation necrosis of the wall. CONCLUSION: On the basis of this feasibility study, radiofrequency thermal ablation is potentially suitable for the ultrasound-guided treatment of symptomatic cystic lesions including benign hepatic or renal cyst.

Three-phase Dynamic CT Findings of Liver Abscess:Related Factors with Multiple Layering Enhancement Pattern

PURPOSE: To determine the number of multiple alternating layers of liver abscess, and changes in this number, as revealed by spiral CT, and to ascertain which factors are related to changes occurring during the three phases of this modality. MATERIALS AND METHODS: Using three-phase spiral CT imaging we studied 26 cases of liver abscess (pyogenic:amebicm=23:3). The number of layers comprising the abscess, as seen on postcontrast CT scans, was determined during the arterial (30sec), portal (70sec), and delayed (220sec) phase, and all cases were assigned to one of two groups according to changes in the number of layers observed during the three phases. With regard to underlying disease, the two groups were compared in terms of the presence of abscess and of diabetes mellitus,CT interval (time from onset of symptoms to CT scanning), microbial agent (pyogenic vs. amebic), and the largest diameter of abscess as revealed by CT. RESULTS: Except in one case, three or four alternating layers [in 13(50%) and 7(27%) cases, respectively] were seen only during the arterial and portal phase. During each of the three phases-and especially the delayed phase, where it was present in 25 of cases (96%)-two alternating layers (2:2:2) was the most common pattern, with a 3:3:3 pattern occurring in one case. All 12 cases (46%) in the unchanging-layer group showed one of these two patterns. All changing-layer group cases (14;54%) demonstrated three or four layers during the arterial and portal phase but only two during the delayed phase. The CT interval was the only significantly different factor between the two groups. During the first week, the number of cases in the unchanging-layer group was much higher than in the changing-layer group (86%,14%), but during the second week this situation reversed (25%, 75%). CONCLUSION: Our study reveals that on three-phase dynamic CT images, a characteristic enhancement feature of liver abscesses is three or four layers during the arterial and portal phases, with reduction to two layers during the delayed phase. This change, as revealed by spiral CT, is rare during the week following the onset of symptoms, but common during the second week.

Radiofrequency Thermal Ablation of Malignant Hepatic Tumors: Post-Ablation Syndrome

PURPOSE: To evaluate post-ablation syndrome after radiofrequency thermal ablation of malignant hepatic tumors. MATERIALS AND METHODS: Forty-two patients with primary (n=29) or secondary (n=13) hepatic tumors under-went radiofrequency thermal ablation. A total of 65 nodules ranging in size from 1.1 to 5.0 (mean, 3.1) cm were treated percutaneously using a 50W RF generator with 15G expandable needle electrodes. We retrospec-tively evaluated the spectrum of post-ablation syndrome including pain, fever(> or =38 C degrees), nausea, vomiting, right shoulder pain, and chest discomfort according to frequency, intensity and duration, and the findings were cor-related with tumor location and number of ablations. We also evaluated changes in pre-/post-ablation serum aminotransferase(ALT/AST) and prothrombin time, and correlated these findings with the number of abla-tions. RESULTS: Post-ablation syndrome was noted in 29 of 42 patients (69.0%), and most symptoms improved with conservative treatment. The most important of these were abdominal pain (n=20, 47.6%), fever (n=8, 19.0%), and nausea (n=7, 16.7%), and four of 42 (9.5%) patients complained of severe pain. The abdominal pain lasted from 3 hours to 5.5 days (mean; 20.4 hours), the fever from 6 hours to 5 days (mean; 63.0 hours). and the nau-sea from 1 hour to 4 days (mean; 21.0 hours). Other symptoms were right shoulder pain (n=6, 14.3%), chest discomfort (n=3, 7.1%), and headache (n=3, 7.1%). Seventeen of 20 patients (85%) with abdominal pain had a subcapsular tumor of the liver. There was significant correlation between pain, location of the tumor, and number of ablations. After ablation, ALT/AST was elevated more than two-fold in 52.6%/73.7% of patients, respectively but there was no significant correlation with the number of ablation. CONCLUSION: Post-ablation syndrome is a frequent and tolerable post-procedural process after radiofrequency thermal ablation. The spectrum of this syndrome provides a useful guideline for the post-ablation management.

Radiologic Findings of Renal Hemangioma: Report of Three Cases

Renal hemangioma is an uncommon benign tumor which usually causes painless or painful gross hematuria. Its preoperative diagnosis is extremely difficult or even impossible. We experienced three cases of renal hemangioma, located mainly at the pelvocalyceal junction or in the inner medulla. US demonstrated variable echogenecity, and CT revealed a lack of significant enhancement. Where there is gross hematuria in a young adult, especially when the renal mass located in the pelvocalyceal junction or inner medulla shows little enhancement on CT, renal heman-gioma should form part of the differential diagnosis.

Primary Hepatic leiomyosarcoma: A case Report

Primary hepatic leiomyosarcoma is a rare tumor, most frequently occurring in liver parenchyma. We recentlyencountered an exophytic hepatic leiomyosarcoma ; CT scans indicated an indistinct border, with the parenchyme ofthe liver and parenchymal beaking suggesting a primary hepatic mass. We present an unusual case of primaryleiomyosarcoma which showed exophytic growth.

Systemic Lupus Erythematosus: Abdominal Radiologic Findings

Systemic lupus erythematosus(SLE) is a systemic disease of unknown etiology. Its main pathology is vasculitis and serositis, due to deposition of the immune complex or antibodies. Most findings are nonspecific ; abdominal manifestations include enteritis, hepatomegaly, pancreatic enlargement, serositis, lymphadenopathy, splenomegaly,nephritis, interstitial cystitis, and thrombophlebitis. We described radiologic findings of various organinvolvement of SLE; digestive system, serosa, reticuloendothelial system, urinary system, and venous system.Diagnosis of SLE was done according to the criteria of American Rheumatism Association. Understanding of thevariable imaging findings in SLE may be helpful for the early detection of abdominal involvement andcomplications.

Atrophy of the Left Hepatic Lobe Caused by a Biliary Tract Disease

PURPOSE: To study the CT patterns of left lobar atrophy, including pathologic and hemodynamic features, incases of primary biliary disease. MATERIALS AND METHODS: CT findings of left hepatic lobar and segmental atrophyin 26 patients with histologically or radiologically-proven underlying bile-duct disease were reviewed. Seventeen cases were oriental cholangiohepatitis (OCH) with left intrahepatic stones and nine were cholangiocarcinomainvolving the hilar or left hepatic bile duct. The distribution and appearance of atrophy and adjacent lobarhypertrophy were studied. CT scans were examined for the presence of stenosis or obstruction of the left portalvein, and the enhancing pattern of lobar atrophy was analysed. In patients who had undergone left lobectomy, themechanism of lobar atrophy was correlated with radiographic and pathologic features. RESULTS: All patients showedbile duct dilatation localized to atrophic left hepatic segments. In cholangiocarcinoma, the distribution ofatrophy was characteristically lobar, in contrast to segmental distribution in OCH. Compensatory hypertrophy wasmore common in OCH and particularly involved the caudate lobe. Organic and functional occlusion of the left portalvein was a cause of atrophy, even in OCH. Periportal fibrosis and inflammation were the main pathological featureof atrophy. On spiral CT scan, delayed enhancement of atrophic liver parenchyma was the characteristic feature. CONCLUSION: Lobar or segmental left hepatic lobe atrophy is seen in bile duct disease caused by OCH orcholangiocarcinoma. This finding suggests that the disease process is advanced, and that there is obstruction ornarrowing of the left portal vein, associated with periportal fibrosis and inflammation.