What are the next steps in managing a patient with an ill-defined hypodensity in the left hepatic lobe, multiple abdominal wall hernias, and back pressure changes in the right pelvicalyceal system?

Management of Multiple Hepatic and Abdominal Findings

This patient requires urgent contrast-enhanced CT or MRI of the liver with hepatic protocol to characterize the 7.1 cm left hepatic lobe hypodensity, as this is highly concerning for malignancy and cannot be adequately assessed without intravenous contrast. 1, 2

Immediate Priority: Hepatic Lesion Characterization

The 7.1 cm ill-defined hypodensity in the left hepatic lobe is the most critical finding requiring immediate action. The American College of Radiology recommends that for indeterminate lesions >1 cm discovered on noncontrast CT in patients without known chronic liver disease, the next step is either multiphase contrast-enhanced CT or MRI with and without IV contrast as equivalent first-line options. 1, 2

Recommended Imaging Protocol

• MRI with and without IV contrast is preferred as it establishes a definitive diagnosis in 95% of liver lesions versus 74-95% for CT, and only 1.5% require further imaging after MRI versus 10% after CT. 2, 3
• If MRI is contraindicated or unavailable, perform triple-phase contrast-enhanced CT (arterial, portal venous, delayed phases) with 2.5-5 mm slice thickness. 1
• The size of this lesion (7.1 cm) places it at high risk for malignancy, particularly intrahepatic cholangiocarcinoma or metastatic disease, though benign lesions like hemangioma remain possible. 4, 5

Biopsy Considerations

• Pathological diagnosis is required for definitive diagnosis if imaging remains indeterminate after contrast-enhanced studies, particularly if systemic chemotherapy or radiation therapy will be considered. 4
• Core needle biopsy is required for definitive diagnosis, not fine needle aspiration. 4
• However, defer biopsy until after diagnostic imaging to avoid unnecessary risk if imaging can establish a benign diagnosis. 2
• Tumor seeding can occur with percutaneous biopsy, though the risk is not well-defined. 4

Secondary Priority: Right Hydronephrosis

The moderate dilatation of the right pelvicalyceal system and proximal ureter with mild kinking requires urological evaluation. 1

Evaluation Steps

• Contrast-enhanced CT urography or MR urography is needed to definitively exclude an obstructive calculus and characterize the cause of obstruction, as the current noncontrast study has limited sensitivity. 1
• The bilateral nonspecific perinephric stranding may represent chronic inflammation or infection and should be correlated with urinalysis and urine culture. 1
• If obstruction is confirmed, urgent urological consultation is needed to prevent irreversible renal damage, particularly if associated with infection.

Tertiary Priority: Multiple Abdominal Wall Hernias

The patient has multiple hernias requiring surgical evaluation, particularly the bilateral inguinal hernias with concerning features. 1

Specific Hernia Concerns

• Left inguinal hernia containing bladder wall (3.5 cm orifice) represents a sliding hernia that requires elective surgical repair to prevent incarceration and bladder injury. 1
• Right inguinal hernia with 27 x 40 mm isodensity could represent fluid, bowel, or omentum; contrast-enhanced imaging would better characterize contents and assess for complications. 1
• Epigastric hernia with soft tissue stranding and nodularities (2.6 x 2.2 cm) raises concern for incarcerated fat or omentum; clinical correlation for tenderness is essential. 1

Surgical Referral Timing

• If any hernia shows signs of incarceration (persistent pain, tenderness, inability to reduce), urgent surgical consultation is required.
• Otherwise, elective surgical consultation should occur after the hepatic lesion is characterized, as this may affect surgical planning and anesthetic risk.

Additional Findings Requiring Attention

Gastric Wall Thickening

• The thickening of gastric folds in the fundus and body with coarse, ill-defined mucosa requires upper endoscopy to exclude gastric malignancy, particularly given the large hepatic lesion. 1
• Gastric lymphoma, adenocarcinoma, and infiltrative processes can present with this appearance. 1
• Correlation with any prior endoscopy is essential, but if none exists, endoscopy should be performed after hepatic imaging to complete staging if malignancy is found.

Osseous Findings

• The 8.5 mm focal lucency in the left iliac bone requires correlation with the hepatic lesion characterization, as it could represent a metastatic focus if the liver lesion proves malignant. 1
• The punctate sclerosis in the left ischium is likely a benign bone island but should be reassessed if systemic malignancy is diagnosed. 1

Recommended Action Sequence

1. Schedule urgent MRI liver with and without IV contrast (or triple-phase CT if MRI contraindicated) within 1-2 weeks. 1, 2
2. Obtain tumor markers including AFP, CEA, CA 19-9 prior to imaging to aid in lesion characterization. 4
3. Perform contrast-enhanced CT urography or refer to urology for evaluation of right hydronephrosis. 1
4. Schedule upper endoscopy after hepatic imaging results are available. 1
5. Refer to general surgery for hernia evaluation, with timing dependent on hepatic lesion diagnosis. 1
6. If hepatic imaging shows malignant features, refer to interventional radiology for image-guided biopsy with CEUS guidance if needed. 2, 3
7. If biopsy confirms malignancy, multidisciplinary tumor board discussion should determine staging and treatment planning. 3

Critical Pitfalls to Avoid

• Do not delay hepatic imaging waiting for other evaluations; the 7.1 cm lesion is the highest priority finding. 1, 2
• Do not perform biopsy before diagnostic contrast-enhanced imaging, as this may be unnecessary if imaging establishes a benign diagnosis. 2
• Do not assume the hepatic lesion is benign based on noncontrast imaging alone; evaluation is severely limited without IV contrast. 1
• Do not ignore the gastric findings; they may represent synchronous malignancy or be related to the hepatic process. 1