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Spontaneous rupture of liver tumor

Case contributed by Hoe Han Guan
Diagnosis probable

Presentation

Acute onset of shortness of breath, epigastric pain and syncope. No history of preceding trauma.

Patient Data

Age: 60 years
Gender: Male

Flattening of right hemidiaphragm with lateralization of its peak (comparing with the normal left hemidiaphragm) may represent subpulmonic effusion or subphrenic ascites/collection.
Both costophrenic angles are sharp.
No widening of mediastinum. No cardiomegaly.
No abnormal lung lesion or consolidation.

Patient was treated as acute coronary syndrome (ACS) and given double anti-coagulation. After one days of hospital admission, patient collapsed and resuscitation initiated. Urgent CT angiogram thorax, abdomen and pelvis performed to rule out aortic aneurysm or dissection.

A heterogeneously enhancing liver lesion at segment VII/VIII.
Large right sided subcapsular hepatic hematoma which extends from the right hemidiaphragm to the inferior edge of liver segment VI. Sentinel clot sign noted within this subcapsular hematoma to suggest the bleeding site is likely from the liver lesion.
On plain study, high density ascites (30HU) at perihepatic, perisplenic, bilateral paracolic gutters and pelvic regions in keeping with hemoperitoneum.
On arterial and portovenous phases, contrast blush from the superior aspect of the liver lesion with further pooling of contrast within the subcapsular hematoma at the delayed scan. This is in keeping with active bleeding from rupture of the liver tumor.
Liver is normal in size with smooth and regular margin.
Portal veins are well opacified without thrombosis.

Flattening of inferior vena cava and reduced enhancement of solid organs represent the hypovolemic state.
Cholelithiasis.

Annotated image

Annotated images for chest radiograph and specific CT axial images.

Case Discussion

This case showed CT findings of active bleeding from spontaneous rupture of liver tumor. The differential diagnosis would be hepatic adenoma or hepatocellular carcinoma. Multi-phases CT scan (plain, arterial, portovenous and delayed scans) is very useful if clinical suspicion of active bleeding. Patient passed away one day after this CT scan even with rigorous resuscitation. Unable to get histopathological result of the liver tumor.

The subtle radiographic sign of flattening of hemidiphragm and lateralization of diaphragm peak would be useful to detect subpulmonic/subphrenic effusion, where this can lead to proper imaging modality such as ultrasound abdomen for further investigation. Overlooked of this subtle radiographic sign has lead to wrong diagnosis and treatment for this patient which further leading to devastating complications of worsening hemorrhage and hypovolemic shock.

Case co-contributor of Dr. Nurliyana Izyan Binti A Halim, Hospital Ampang, Malaysia.

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