A Case of Spontaneous Liver Rupture as a Cause of Hemoperitoneum

Abstract

A 51 y/o Chinese male hepatitis B carrier, presented with dull RUQ pain and abdominal distention. Vitals were T 37.8, HR 100, BP 117/60. Exam notable for soft and distended abdomen, shifting dullness, periumbilical bruise, but no stigmata of cirrhosis. Labs were H/H 7.2/22.3, WBC 7.1, Plt 179, BUN/Cr 34/2.1, INR 1.5, Alb 3.1, AST 176, ALT 133, Alk Phos 530, T bili 0.8, Lactate 4.4, ABG 7.42/32/64. CT revealed moderate hemorrhagic ascites, hepatomegaly with steatosis, and prominent perigastric lymph nodes. Paracentesis revealed bloody fluid, RBC 2,420,000, HCT 19%, WBC 260 (75% PMN), Alb 1.7 (SAAG 1.4). Cultures were negative (including AFB). Cytology revealed reactive mesothelial cells but no malignancy. LDH was > 2000 raising suspicion for lymphoma with liver infiltrative disease. CT angiogram was performed (see Figure 1).Figure 1Liver biopsy was planned, however the patient became unstable. Hgb was 6, lactate 21, and arterial pH 6.9. Hemorrhagic shock was suspected. Massive transfusion protocol was initiated. Patient went for exlap where 3L bloody ascites was evacuated. Intraoperatively, the liver appeared nodular, swollen, with multiple briskly bleeding cracks in parenchyma. The liver was packed with pads. Patient then underwent hepatic artery embolization. He soon went into acute liver failure and expired. Autopsy was not performed. Etiology of liver disease suspected to be an infiltrative process (i.e. amyloid secondary to a hematologic malignancy or lymphoma itself). SH is rare but life-threatening. It can be the result of non-traumatic intra-abdominal organ rupture or abdominal vasculature pathology. Surgery and/or angioembolization are the mainstays of treatment.1 Liver etiologies of SH include HCC rupture, hemangioma rupture, adenoma rupture, HELLP syndrome, infiltrative disease (i.e. amyloid), and peliosis hepatis2,3,4,5. Diagnosis relies on imaging such as ultrasound or CT.5 Early surgical intervention is critical in this highly morbid disease.