The Case Files

Abstract

A 59-year-old woman presented to the emergency department complaining of worsening abdominal pain and distension as well as four episodes of syncope and lightheadedness. The patient reported a past medical history of hypertension and hypothyroidism, but denied other comorbidities. The patient reported that she was walking her dog the previous night when the dog bolted forward, causing her to lose her balance and fall forward. The patient reported that she was able to tuck into a ball and roll, sustaining minor trauma only to her right side. She denied any head trauma or loss of control after falling. She was able to walk home, and she felt fine apart from some bruising on her right lower ribs. Over the course of the evening, however, the patient's pain began to worsen. She had several episodes of nausea and non-bloody, non-bilious emesis. The next morning she began to feel short of breath, and her abdominal pain continued to worsen. She reported two episodes of syncope, which she attributed to the severity of her pain or because she was breathing too quickly.FigureFigureThe patient's systolic blood pressure was in the 80s when she arrived in the ED, and her heart rate was 130 bpm. Her respiratory rate was 26 bpm, and her SPO2 was 85% on room air. The patient was in distress and started on oxygen, intravenous access was obtained, and she was resuscitated with normal saline. She had significant abdominal pain that seemed to localize to the right upper quadrant, and a bedside FAST exam was positive for intra-abdominal fluid. The patient was expeditiously transferred to a trauma center where she underwent a CT with IV contrast for the abdomen and pelvis. A large smoothly marginated cystic lesion was noted on the dome of the right hepatic lobe measuring 13.1 x 8.6 cm. A grade 3 liver laceration was noted at the base of the hepatic cysts with a surrounding large hematoma. Moderate amounts of fluid were noted in Morrison's pouch, the surrounding paracolic gutter, and the pelvis. A fracture was also noted in the right eighth rib that was not displaced. The patient's hemoglobin levels continued to drop, and she was taken to interventional radiology, where she was noted to have a small pseudoanuerysm of a segmental branch of the right hepatic artery within the hepatic cyst, with evidence of active intraperitoneal extravasation. The patient then underwent an embolization of the segmental branch of the right hepatic artery, and hemostasis was successfully obtained. The patient's hemoglobin levels stabilized after the embolization, and she was able to resume a regular diet. She was discharged on hospital day six with the plan to follow up with trauma surgery.FigureFigureFigureUnintended falls are the most common cause of injury in the United States. They lead to 7.9 million emergency department visits per year and 860,000 hospitalizations. (Acad Emerg Med 1998;5[11]:1064.) In our particular case, what appeared to be a benign mechanism resulted in a serious injury because of the presence of a benign hepatic cyst that the patient didn't know about. Simple hepatic cysts are believed to be present in five to 10 percent of the population, with increasing incidence with age. (J Clin Ultrasound 1996;21[2]:115.) Common complications of hepatic cysts include rupture, contained hemorrhage, and obstructive jaundice. (J Nippon Med Sch 2010;77[3]:181; West J Med 1982;136[3]:246; Am J Gastroenterol 1988;83[1]:93.) Multiple cases of traumatic rupture of hepatic cysts are reported, but these are typically contained within the cyst. Few reports exist suggesting hemoperitoneum after cyst rupture. In our case, the rupture of the hepatic cyst was accompanied by a liver laceration, which led to extravasation of blood leading to hemoperitoneum. (HPB Surg 1988;1[1]:81; South Med J 1989;82[5]:667.) Focused bedside ultrasonography and strong clinical suspicion assisted in expediting a transfer to a trauma center where intervention corrected the problem.