Spontaneous Rupture of Liver Haemangioma-A Case Report & Review of Literature

Abstract

A 31yrs old female patient presented with three day history of sudden right upper quadrant pain which progressively worsened over the last 24 hours. She is a known asthmatic controlled by Nasacort inhaler and also a known case of polycystic ovary diseases using oral contraceptive pills over the last 9 years.On physical examination revealed a young female in mild painful distress. Her mucous membrane was pink and moist. She was warm to touch with a temperature of 38.4°C and her vitals were within normal limit. Abdominal examination revealed moderate tenderness in right upper quadrant with mild guarding but no rebound tenderness.An USS of abdomen revealed a normal gall bladder with no peri-cholecystic fluids or gall stones with a normal CBD. However, a 7.77 x 9.42 cm cystic mass was noted in right lobe of liver and there was no free fluid ( Figure 1). A CXR revealed right basal consolidation. Her WBC was elevated 26.2 and she was also anaemic with an Hb of 11 mg/dl. Her renal function as well as electrolytes were within normal limit, however her liver enzymes were elevated AST-600, ALT-1900, ALP-238, GGT-166 with normal serum bilirubin and amylase level.After 24 hours her pain became severe and she became tachycardic with a pulse of 130 bpm with persistently elevated temperature (38.0°C). Her blood pressure and Spo2 was normal. There was decreased air entry at right lung base. Abdominal examination revealed marked tenderness with guarding but no rebound tenderness and there was sluggish bowel sound. Patient Hb had dropped from 10 gm/dl to 8 gm/dl. An Urgent CT scan of abdomen and pelvis with intravenous contrast revealed that the cyst (haemangioma) has ruptured with free fluid (blood) in Morrison pouch and in right Para-colic gutter (Figure 2). Subsequently patient developed moderate respiratory distress and was reviewed by medicine specialist. A Spiral CT of the chest-revealed mild right pleural effusion with fluid in oblique fissure but no evidence of pulmonary embolism. An MRI of abdomen was also performed which reconfirm the ruptured hepatic haemangioma. Patient was admitted in HDU and was managed successfully and discharged home on day-12.Patient had a high ESR of 39 and her liver function test became normal. Her serum alpha fetoprotein, CEA, Ca 19-9, anti-nuclear DNA levels were within normal limit. DiscussionHemangioma is the most common benign tumour affecting the liver [1,2]. Hepatic haemangioma are mesenchymal in origin and usually are solitary. Haemangioma are composed of masses of blood vessels that are atypical or irregular in arrangement and size. Exact aetiology remains unknown [3][4][5].Several pharmacologic agents have been postulated to promote tumour growth. Steroid therapy [6], oestrogen therapy, and pregnancy [7,8] can increase the size of an already existing hemangioma. Our patient was on inhalational steroid therapy for her asthmatic condition and was also on oral contraceptive pills for her polycystic ovarian disease.Incidence rate 2% in USA & the prevalence rate at necropsy is 7.4%, usual...