A 56-year-old man with end-stage liver disease presented to the emergency department with increasing fatigue and an unexplained weight loss of 16 kg over the preceding 3 months. His past medical history included multiple episodes of abdominal pain and ascites for 30 years. He did not consume alcohol. Physical examination demonstrated a blood pressure of 70/50 mm Hg but was otherwise unremarkable. Laboratory studies demonstrated a sodium level of 131 mEq/L (131 mmol/L) (normal range, 135-145 mEq/L [135-145 mmol/L]), potassium level of 5.5 mEq/L (5.5 mmol/L) (normal range, 3.5-5.0 mEq/L [3.5-5.0 mmol/L]), platelet count of 52 ϫ 10 9 /L (normal range, 140 -450 ϫ 10 9 /L), and partial thromboplastin time of more than 100 seconds (normal range, 24.5-35.2 seconds). The results of serology were negative for viral hepatitis. Abdominal magnetic resonance (MR) imaging was performed.
IMAGING FINDINGSBoth the transverse and coronal MR images (Figs 1 and 2) demonstrate inhomogeneity of the hepatic parenchyma with an irregular hepatic contour. Transverse MR images (Fig 1) demonstrate a right adrenal mass with central low T1 signal intensity, peripheral high T1 signal intensity, diffuse high T2 signal intensity, and lack of enhancement after administration of intravenous gadolinium-based contrast material. Coronal MR images (Fig 2) demonstrate enlarged collateral vein, marked narrowing of the intrahepatic inferior vena cava, and splenomegaly.