Lessons Learnt in the Management of Liver Incidentaloma: Peribiliary Gland Hamartoma

Suresh Khanna Natarajan, MD1, T’zu Jen Tan, MD2. 1Khoo Teck Puat Hospital/ NHG-AHPL General Surgery residency program, 2Khoo Teck Puat Hospital

Introduction: Accidentally detected asymptomatic liver tumors have been named as Incidentalomas; the incidence of which is 10-50%. Unfortunately, their histological nature is rarely proven by one method of imaging and even sophisticated technologies do not clear the doubt in 10-40%.

A very rare case of Peribiliary Gland Hamartoma (PGH) was found incidentally during uncomplicated laparoscopic cholecystectomy and we discuss here its management, complications and also the issues involved in such cases.

Case Report: 83-year-old female presented with acute cholangitis due to cholelithiasis/ choledocholithiasis and underwent ERCP. CT abdomen showed non-enhancing hypodense lesion in Segment 4b of liver – an early abscess. Four weeks later, she had a laparoscopic cholecystectomy and intra-operative cholangiogram, during which a 3cm, white, smooth lesion was noted at free edge of left liver lobe.

Laparoscopic intra-operative ultrasound showed that the lesion was solid. Hence a laparoscopic Trucut biopsy was done. Incidentally brisk bleeding was noted in anterior surface of left lobe, 3-4cm away from biopsy site, which was secured by hook diathermy and laparoscopic suturing.

Post-operatively, the patient developed hypotension & rapid decline in haemoglobin level. Emergency CT mesenteric angiogram showed contrast blush from anterior branch of left hepatic artery, which was embolized with gel foam and coil. Patient was stable after. Histopathology was reported as PGH.

Discussion: Currently, there are no evidence-based guidelines regarding appropriate approach to diagnosis, interpretation of imaging and indication for surgical resection for incidentalomas.

PGH, also known as intrahepatic bile duct adenoma, cholangioma, benign cholangioma, cholangioadenoma or simply bile duct adenoma, is a rare benign epithelial hepatic tumor originating from bile duct cells usually discovered incidentally at autopsy or laparotomy with an incidence of 1.3%. Pathogenesis of PGH is still unclear but it is considered a reactive process to focal bile ductular injury caused by trauma or inflammation rather than true neoplasm.

The issues here are: whether to biopsy incidentaloma and availability of frozen section. If lesion is reported as benign it may be followed up, whereas if report is malignant, then it cannot be resected during same operation owing to incomplete work-up for a major operation, consent issues, availability of expertise and technical support. Also to be considered are possibility of unfortunate complication due to biopsy (like our patient) and managing the same. Later radiology may be the only means of assessing the lesion, which may not be reliable in some rare cases. Percutaneous image-guided biopsy is controversial in itself.

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