Clinical challenges and images in GI.

*Department of Gastroenterology, Hospital Braga, Braga; ‡Life and Health Sciences Research Institute (ICVS), School of Health Sciences, University of Minho, Braga; and §ICVS/3B’s – PT Government Associate Laboratory, Braga/Guimarães, Portugal 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 Question: A 29-yearold white man was brought to our department with a presumptive diagnosis of diffuse hepatic metastasis. He was complaining of anorexia and abdominal right upper quadrant discomfort over the last 2 months. On physical examination he had a nodular liver border, 2-cm beow the right costal margin. Abdominal ultrasonography and computed tomography were performed, revealing the presence of ultiple nodules diffusely distributed throughout the liver parenchyma. The patient referred a history of asthma, recently medicated ith montelukast, and denied alcohol intake or hepatotoxic drug exposure. Liver tests demonstrated slightly elevated aspartate minotransferase (64 U/L), alanine aminotransferase (98 U/L), and -glutamyltransferase (270 U/L) levels. The remaining blood tests (tumor markers— -fetoprotein, carcinoembryonic antigen, and CA19.9; viral serologies; autoimmunity; ceruloplasmine; HFE genotype), as well as upper GI endoscopy and ileocolonoscopy, were normal. The subsequent investigation with abdominal magnetic resonance imaging and magnetic resonance angiography (Figure A, B) revealed an abnormal vascular structure (arrows) and elucidated this clinical situation. What is the most likely diagnosis? Look on page 000 for the answer and see the GASTROENTEROLOGY web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI.