Thursday, August 26, 2010

Young Woman with Abdominal Pain

A 30 year old woman presents with abdominal pain, your favorite chief complaint for that demographic. The pain is in the epigastric and RUQ areas. You note hepatomegaly with no Murphy's sign. Her urinary pregnancy test is negative; she protests, "I take my oral contraceptive religiously, like I have for the last fifteen years." You find that she's visited her primary care doctor multiple times with no diagnosis. Finally, you succumb to CT scan.

Whoa! You did not expect to see that. This CT shows a large complex enhancing mass of the left lobe of the liver with displaced vessels (small arrowheads). A smaller low attenuation mass is also noted in the right lobe of the liver.

While coming out of the CT scanner, she screams in pain and collapses. Her blood pressure is 60/palp. You start resuscitating her aggressively and the surgeons take her to the OR immediately. They find gross blood in the peritoneum.

Challenge: By textbook, this lesion is usually solitary in the right lobe of the liver, but this patient's history makes her prone to more complex lesions such as this one. What's the most likely diagnosis?

Image shown under Fair Use.


city said...

multiple hepatic hemangiomas, one of which ruptured.

sid said...

Hepatic Adenoma.....Usually seen in women with a long history of OCP use.... Most common complication is intraperitoneal h'age....

Craig Chen said...

oh I like both answers - hemangiomas and adenomas can both rupture and cause severe bleeding - when i initially wrote the case, i was thinking adenoma.
Young Woman with Abdominal Pain

Hepatic adenomas are benign epithelial liver tumors seen in young women associated with oral contraceptive use. Rupture can lead to hemodynamic collapse and intraabdominal bleeding.

Source: UpToDate, original image courtesy Jonathan Kruskal.