Hepatik sarkoidoz ve granülomatöz tutulum

Özet

Hepatik sarkoidoz, sistemik sarkoidozda granülomların karaciğeri tutmasıdır; çoğu olguda BT parankimi homojen gösterir ve görüntüleme bulgusu olmayabilir. Daha belirgin hastalıkta hepatomegali ve portal fazda çevre karaciğerden düşük atenüasyonlu, çoğunlukla belirgin çevresel kontrastlanma göstermeyen nodüller görülebilir. Dalak ve abdominal lenf nodlarının birlikte tutulması sistemik dağılımı destekler, ancak enfeksiyon ve maligniteyi dışlamaz. Nodülleri metastaz veya mikroabse sanmak yanlış evreleme ve gereksiz ileri işlem riskini doğurabilir.

Faz ve pencere

Portal tanısal

Granülom kümeleri çevre parankime göre hipodens, çoğu kez belirgin periferik kontrastlanma göstermeyen küçük nodüller veya birleşen coğrafi alanlar şeklinde izlenebilir; ince kesitlerde görünürlük artar.

Önerilen pencereler: Karaciğer (G 150 / M 30), Batın (G 400 / M 50), Yumuşak doku (G 400 / M 40).

BT bulguları

• Hepatomegali; karaciğer boyutu normal olsa bile granülomatöz tutulum bulunabilir
• Parankim çoğu hastada homojen görünür; diffüz heterojenlik veya düşük atenüasyonlu septa benzeri alanlar eşlik edebilir
• Nadiren dağınık, çevre karaciğerden düşük atenüasyonlu nodüller görülür
• Nodüller çoğu kez belirgin halka tarzı kontrastlanma göstermez; boyut ve dağılım değişkendir
• Splenomegali ve dalakta hipodens nodüller sistemik hepatosplenik tutulumu destekler
• Porta hepatis ve üst batın lenfadenopatisi eşlik edebilir
• Kalsifikasyon olabilir ancak sık görülen veya tek başına tanı koyduran bir işaret değildir

Normalde

Normal karaciğer portal fazda homojen kontrastlanır ve içinde çoklu, çevresinden daha düşük atenüasyonlu nodüller bulunmaz; dalak da homojen görünür. Aynı düzeyde karaciğer ve dalak parankimini, porta hepatis lenf nodlarını ve organ boyutlarını kıyasla; sarkoidozda tek bir odak yerine iki organdaki birlikte dağılım tanısal bağlam sağlar.

Ayırıcı tanı

Hepatik metastazlar

halka tarzı veya hedef benzeri kontrastlanma, bilinen primer tümör ve diğer organlardaki metastazlar ayrımı destekler.

Mikobakteriyel veya fungal granülomatöz enfeksiyon

nekroz, çevresel kontrastlanan mikroabse odakları ve immün baskılanma ya da enfeksiyon bağlamı öne çıkar.

Hepatik lenfoma

birleşen kitleler, periportal infiltrasyon ve daha yaygın lenfadenopati görülebilir.

Biliyer hamartomlar, BT’de karaciğerin her iki lobuna yayılmış çok sayıda düşük atenüasyonlu odak şeklinde görülebilir.

Hemanjiomlar arteriyel faz BT'de periferik nodüler kontrastlanma gösterebilir.

Tuzaklar

• Hepatik sarkoidozun çoğu olgusunda BT nodül göstermez; normal parankim görünümü sistemik hastalığı dışlamaz.
• Hipodens nodüller metastaz, tüberküloz veya mantar mikroabseleriyle karışabilir; toraks, dalak ve lenf nodu dağılımını birlikte değerlendir.
• Nodül yokken yalnız hepatomegali ya da lenfadenopatiye dayanarak karaciğer sarkoidozu tanısı koyma.
• Nodül sayısı veya boyutu için sarkoidoza özgü BT tanı eşiği yoktur; kaynaklarda bildirilen ölçümler bir sınıflama ölçütü değildir.

Kendini dene

1. Sarkoidoz öykülü hastada portal BT'de hepatomegali, birkaç hipodens karaciğer nodülü ve benzer dalak odakları var; belirgin halka kontrastlanması yok. En olası açıklama nedir?

   • Hepatosplenik sarkoidoz
   • Karaciğer mikroabseleri
   • Hemanjiomlar
   • Biliyer hamartomlar
   Cevabı göster

   Hepatosplenik sarkoidoz. Bilinen sistemik sarkoidoz, karaciğer ve dalakta birlikte düşük atenüasyonlu nodüller ve belirgin çevresel kontrastlanma yokluğu granülomatöz tutulumu destekler. Mikroabseslerde periferal halka tarzı kontrastlanma ve immün baskılanma bağlamı öne çıkar.

2. Çoklu düşük atenüasyonlu karaciğer odaklarında arteriyel fazda periferik nodüler kontrastlanma görülüyor. Hangi tanı daha olasıdır?

   • Hemanjiom
   • Hepatik sarkoidoz
   • Lenfoma
   • Biliyer hamartom
   Cevabı göster

   Hemanjiom. Arteriyel fazda periferik nodüler kontrastlanma hemanjiom lehinedir. Sarkoidoz nodülleri çoğunlukla belirgin kontrastlanma göstermez; lenfoma solid, hipodens nodüller ve vasküler yapı bozukluğu ile ayrılır.

Kaynaklar

Bu sayfadaki 36 cümle ve 2 quiz sorusu aşağıdaki kaynaklardan alıntılarla tek tek karşılaştırıldı; 6 cümle bu karşılaştırmada düzeltildi (2026-10-09).

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