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  • Small liver with irregular, scalloped margins, abnormal architecture
  • Mildly heterogeneous parenchyma post-contrast
  • Enlarged intrahepatic portal veins (right worse than left)
  • Plexus of anomalous small, tortuous vessels in the mid dorsal abdomen near the level of the renal and phrenicoabdominal veins
  • Mild hepatic and mesenteric lymphadenopathy
  • Moderate splenomegaly
  • Chronic liver disease with suspected portal hypertension and multiple acquired portosystemic shunts (chronic hepatitis, cirrhosis)
  • Mild hepatic and mesenteric lymphadenopathy, likely reactive
  • Splenomegaly – secondary to anesthesia or less likely infiltrative disease

Based on the average scores, this was one of the more difficult cases of the section. Candidates that performed well recognized all the key findings (small, irregularly marginated liver and anomalous vessels adjacent to the renal and phrenicoabdominal veins) and gave cirrhotic or chronic liver disease with secondary portal hypertension and multiple acquired shunts as the top differential diagnosis. Minor findings such as hepatic lymphadenopathy and splenomegaly were recognized as minor/incidental, and benign differentials were considered more likely (reactive lymphadenopathy, congestion secondary to sedation/anesthesia) than aggressive lesions.

A large number of candidates did not identify or describe the vascular abnormalities.

Some candidates misinterpreted the liver as being enlarged and described a liver mass, giving neoplastic and/or fungal disease as primary differential diagnosis for both the liver and spleen. These candidates did not recognize the vascular abnormalities

A few candidates recognized the liver as small, and described looking for but not being able to identify a congenital portosystemic shunt. Some of these candidates described a single congenital portosystemic shunt and said surgery was necessary. Others recommended abdominal ultrasound to find the congenital shunt.

A few candidates described a pancreatic mass and gave pancreatic cancer with metastasis as the top differential diagnosis.