Fatal haemoperitoneum due to liver metastases from nasopharyngeal cancer

Spontaneous hepatic haemorrhage: a review of pathogenesis, aetiology and treatment

BACKGROUND

A spontaneous hepatic haemorrhage (SHH) is a rare condition that presents acutely to both hepatobiliary and general surgeons. Management of the condition is challenging because of the emergent presentation requiring immediate intervention, the presence of underlying chronic liver disease and the multiple potential underlying aetiological conditions.

METHODS

A literature search on a spontaneous hepatic haemorrhage was instituted on Medline (1966-2014), Cochrane Register of Controlled Trials, EMBASE (1947-2014), PubMed, Web of Science and Google Scholar. The specific topics of interest were causes - including rare causes, pathophysiological mechanisms and management options. A narrative review was planned from the outset.

RESULTS

After 1546 abstracts were reviewed, 74 studies were chosen for inclusion. Hepatocellular carcinoma (HCC) is the commonest cause of a spontaneous haemorrhage with 10% of HCC presenting with bleeding. Other causes are benign hepatic lesions (hemangioma, adenoma, focal nodular hyperplasia, nodular regenerative hyperplasia, biliary cystadenoma and angiomyelolipoma), malignant hepatic tumours (angiosarcoma, haemangioendothelioma, hepatoblastoma and rhabdoid sarcoma), peliosis hepatis, amyloid, systemic lupus erythematosis, polyarteritis nodosa, HELLP syndrome and acute fatty liver of pregnancy. Treatment practice emphasizes arterial embolization to obtain haemostasis with a hepatectomy reserved for tumour-bearing patients after staging and assessment of liver function.

CONCLUSION

A spontaneous hepatic haemorrhage is an acute presentation of a spectrum of conditions that requires early diagnosis and multidisciplinary management.

Bleeding from ruptured hepatic metastases as a cause of syncope in an octogenarian: a case report

Introduction

Acute hemoperitoneum as a result of hemorrhage from liver metastases is an uncommon but serious condition. The use of appropriate imaging is important in the diagnosis and can have a profound impact on subsequent management. This case is important because the presentation was of recurrent syncopal episodes with an unusual underlying cause. This case highlights the need to consider this diagnosis in the differential in patients presenting with collapse in the acute setting.

Case presentation

We present the case of an 85-year-old Caucasian man who was admitted following a collapse episode and was found to be persistently hypotensive despite aggressive resuscitation. An acute intra-peritoneal bleed originating from hepatic metastases from an unknown primary was identified promptly with computed tomography imaging and was subsequently managed conservatively.

Conclusions

This case aims to convey key teaching points: (A) the need to consider intra-abdominal hemorrhage in the differential diagnosis when assessing patients with collapse; and (B) the use of appropriate imaging such as computed tomography can facilitate a prompt diagnosis and appropriate management steps can then be taken accordingly.