Multiple biliary microhamartomas diagnosed in an unsuspecting elderly patient

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INTRODUCTION

Multiple biliary hamartomas are relatively rare and often an incidental finding during imaging studies. Identifying and accurately diagnosing these lesions are crucial because they can mimic other hepatic lesions, such as cysts or tumors, leading to potentially unnecessary invasive procedures or treatments [1-4].

DESCRIPTION OF THE CASE

Medical History

An 82-year-old male presented to the hospital with a primary complaint of abdominal pain persisting for more than 6 weeks. The patient has no personal/family history significant for liver disease. A thorough medical evaluation, including physical examination and blood tests, was conducted. However, these initial assessments did not yield conclusive results nor provide a clear diagnosis.

Diagnostic Assessment

The patient underwent contrast-enhanced CT (computed tomography) and subsequently MRI [5–6].

Multiple millimetric disorganized hypodense lesions, both subcapsular and intraparenchymal, were detected incidentally in both hepatic lobes on CT.

After the administration of contrast medium, enhancement of lesions was not observed (Fig. 1).

 

Fig. 1. Axial CT image: hypodense lesions without significant contrast enhancement in the arterial and venous phases.

 

Subsequent MRI examination identified the same lesions with different characteristics in various sequences. In T2-weighted MRI images, the areas appear homogeneously and intensely hyperintense (Fig. 2).

 

Fig. 2. Coronal and axial MRI images with HASTE T2 sequence: multiple small hyperintense lesions throughout the hepatic area.

 

In T1-weighted images, all the lesions were homogeneously hypointense.

In diffusion-weighted imaging (DWI), the lesions persist as hyperintense at a low B-value (50 sec/mm²) but disappear at a high B-value (800) (Fig. 3).

 

Fig. 3. Axial MRI image with DWI sequence: hyperintense lesions at low B-value (50 sec/mm2) on the right, disappearing at high B-values on the left (800).

 

In T2-weighted MRI–cholangiography sequences, the liver presents a “starry sky” appearance due to the presence of multiple small hyperintense lesions; however, the communication with the bile duct are usually not recognized [7] (Fig. 4).

 

Fig. 4. MRI image with T2 MRI–cholangiography sequence: multiple small hyperintense lesions; the liver with a “starry sky” appearance.

 

The dynamic study after contrast administration did not show enhancement in the arterial and venous phases (Fig. 5).

 

Fig. 5. Axial MRI image with T1 sequence showing hypointense lesions without significant contrast enhancement in the arterial and venous phases.

 

Differential Diagnosis

Radiographic findings may be nonspecific and may not differentiate biliary hamartomas from other lesions.

The differential diagnosis is made with polycystic liver disease, multiple simple hepatic cysts, metastases, micro-abscesses, and Caroli’s disease [8]. A more heterogeneous appearance of lesions and communication with the bile duct is observed in the latter.

Interventions

In the present case, the lesions were not directly related to symptoms or complications therefore, no surgical or pharmacological treatment was required.

If Von Meyenburg complexes are causing symptoms or complications, treatment may include surgical removal of the affected liver tissue or drainage of large cysts [9–11].

It is critical for individuals diagnosed with these complexes to consult a hepatologist or liver specialist to determine the appropriate management approach based on their specific case.

Follow-up and Outcomes

The management of the patient’s condition was based on observation and scheduled monitoring, allowing for the timely assessment of any potential alterations. However, no significant changes led to alterations in the diagnostic choices made.

DISCUSSION

Multiple biliary hamartomas, also called Von Meyenburg complexes, are rare benign liver lesions characterized by small disorganized cystic structures affecting both hepatic lobes with some predilection for subcapsular regions [12–13]. They are multiple small round, or irregular lesions and are usually 5–30 mm in size on imaging.

These structures are composed of abnormal bile ducts and are typically discovered incidentally during medical imaging studies, such as ultrasound, CT, and MRI, which are often performed for other reasons. Although hamartomas can communicate with the biliary tree, but usually not. They are believed to arise from embryonic bile duct remnants that have failed to involute.

Von Meyenburg complexes are considered noncancerous and are usually asymptomatic. They are generally not associated with liver dysfunction or clinical symptoms. Laboratory data are generally nonspecific and within normal limits. Most individuals with these lesions do not require treatment. In some cases, Von Meyenburg complexes can be associated with various liver conditions, including polycystic liver disease, Caroli’s disease, and congenital hepatic fibrosis [14].

When these conditions are present, they can lead to more significant liver-related problems and may require medical management.

CONCLUSION

Von Meyenburg complexes a rare medical condition that is often detected incidentally. This study highlights the importance of accurate diagnosis and challenges in distinguishing these lesions from other hepatic lesions. Management based on observation and periodic monitoring is a feasible approach when the lesions are asymptomatic. However, clinical awareness on multiple biliary hamartomas is crucial to avoid misdiagnosis and unnecessary invasive interventions. Future studies may further our understanding of this condition and its clinical implications.

ADDITIONAL INFORMATION

Funding source. This study was not supported by any external sources of funding.

Competing interests. The authors declare that they have no competing interests.

Authors’ contribution. All authors made a substantial contribution to the conception of the work, acquisition, analysis, interpretation of data for the work, drafting and revising the work, final approval of the version to be published and agree to be accountable for all aspects of the work.

Consent for publication. Written consent was obtained from the patient for publication of relevant medical information and all of accompanying images within the manuscript in Digital Diagnostics Journal.

Sobre autores

Marina Balbino

University of Foggia

Email: marinabalbino93@gmail.com
ORCID ID: 0009-0009-2808-5708

MD

Itália, Foggia

Manuela Montatore

University of Foggia

Email: manuela.montatore@unifg.it
ORCID ID: 0009-0002-1526-5047

MD

Itália, Foggia

Giacomo Fascia

University of Foggia

Email: giacomo.fascia@unifg.it
ORCID ID: 0000-0001-5244-5093

MD

Itália, Foggia

Ruggiero Tupputi

Dimiccoli Hospital

Email: rutudott@gmail.com

MD

Itália, Barletta

Federica Masino

University of Foggia

Email: federicamasino@gmail.com

MD

Itália, Foggia

Gianmichele Muscatella

University of Foggia

Email: muscatella94@gmail.com
ORCID ID: 0009-0004-3535-5802

MD

Itália, Foggia

Domenico Mannatrizio

University of Foggia

Email: dr.mannatrizio@gmail.com
ORCID ID: 0000-0003-3365-7132
Itália, Foggia

Giuseppe Guglielmi

University of Foggia; Dimiccoli Hospital; Casa Sollievo della Sofferenza Hospital

Autor responsável pela correspondência
Email: giuseppe.guglielmi@unifg.it
ORCID ID: 0000-0002-4325-8330

MD, Professor

Itália, Foggia; Barletta; Foggia

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