The nodules were located in the VII and VIII segments and had diameters of 24 and 39 mm, respectively. For characterization and staging, CEUS and contrast-enhanced computed tomography were performed. Both techniques showed intense and homogeneous arterial enhancement (Fig. 1A,B) followed by washout in the portal and delayed phases (Fig. 1D,E). In order to complete the genetic and immunochemical study protocol, biopsy was performed on both nodules. The lesion in the VIII segment ERK inhibitor was revealed

to be well-differentiated ICC (Fig. 1C), whereas the other lesion showed features of well-differentiated HCC (Fig. 1F). This case clearly demonstrates the risk of accepting imaging findings as conclusive for HCC in the setting of liver cirrhosis and the risk of considering the largest of multiple nodules to be representative of all others. The AASLD guidelines should be amended with respect to the possible misdiagnosis of lesions whose imaging simulates HCC but that are due to different diseases (e.g., ICC or non-Hodgkin’s lymphoma) and with respect to synchronous nodules occurring in patients with cirrhosis. In conclusion, our case and the results of Vilana et al.1 confirm that aimed biopsy is the most accurate option for a confident diagnosis buy CH5424802 of liver nodules.4 The AASLD diagnostic

criteria increasingly seem to display evidence of low sensitivity and specificity, and this suggests the need for redefinition. Giorgia Ghittoni M.D.*, Eugenio Caturelli M.D.†, Sandro Rossi M.D.*, * Medicina VI, Ecografia Interventistica, Istituto di Ricovero selleckchem e Cura a Carattere, Scientifico Policlinico San Matteo, Pavia, Italy, † Unità Operativa di Gastroenterologia, Ospedale Belcolle,

Viterbo, Italy. “
“We read with interest the study by Solà et al.,1 who found that 39 patients (67%) had a very alarming decrease in their serum sodium levels ≥ 5 mEq/L during terlipressin treatment for acute variceal bleeding (AVB). We, however, feel that some of their observations may require a closer look by the readers. Terlipressin for AVB has been evaluated in a number of studies, but hyponatremia has not been mentioned, has not been found significant, or has not been examined in most. Escorsell et al.2 observed hyponatremia in 4 of 105 patients (3%) treated with terlipressin; similarly, Feu et al.3 observed 5 cases of hyponatremia among 80 patients (6%) with AVB. At our center, 47 patients were treated with band ligation along with terlipressin (2 mg every 6 hours for the first 48 hours and then 1 mg every 6 hours for the next 3 days) over the last 12 months [age = 50.4 ± 11.9 years, hemoglobin level = 8.1 ± 2.1 g %, median total bilirubin level = 2.3 mg % (range = 1.0-27.0 mg %), serum sodium level = 132.2 ± 6.3 mmol/L, serum albumin level = 2.5 ± 0.5 g %, median serum creatinine level = 0.