Aetio-pathogenesis and the management of spontaneous liver bleeding in the West: a 16-year single-centre experience

A Close Clinical Workup of a Spontaneous Idiopathic Hepatic Rupture

Atraumatic spontaneous liver rupture is a very rare occurrence. Most case reports and case series focus on patients during pregnancy, conditions associated with malignancy, hepatomegaly/hepatic pathology, benign masses/lesions, or infectious etiologies. This case report presents a unique circumstance where none of the above-mentioned etiologies were evident at the initial presentation or during the clinical workup. The patient presented with some non-specific symptoms of biliary colic without a conclusive diagnosis before the hepatic rupture. Given the high morbidity and mortality associated with spontaneous liver rupture, we believe this case allows for a closer look at the pre-rupture presentation and eventual sequelae not mentioned elsewhere in the literature.

Hepatic adenoma: evolution of a more individualized treatment approach

BACKGROUND

Hepatic adenomas (HAs) are benign, solid liver lesions, which carry a risk of hemorrhage and malignant transformation. This review article highlights the advances in the diagnosis and management of HAs.

METHODS

A comprehensive review was performed using MEDLINE/PubMed and Web of Science databases with a search period ending on September 30, 2023. Using PubMed, the terms "hepatocellular," "hepatic," and "adenoma" were searched.

RESULTS

HA has been classified into at least 8 subtypes based on molecular pathology, each exhibiting unique histopathologic features, clinical considerations, and risk of malignant transformation. The most common subtype is inflammatory HA, followed by hepatocyte nuclear factor 1α-inactivated HA, β-catenin exon 3-mutated HA (βex3-HA), β-catenin exon 7- or 8-mutated HA, sonic hedgehog HA, and unclassified HA. Magnetic resonance imaging is the best imaging method for diagnosis and can distinguish among HA subtypes based on fat and telangiectasia pathologic characteristics. The risk of malignant transformation varies among molecular subtypes, ranging from <1% to approximately 50%. Up to 42% of HAs present with spontaneous intratumoral hemorrhage and peritoneal hemorrhage. In general, only 15% to 20% of patients require surgery. HA larger than 5 cm are more likely to be complicated by bleeding and malignant transformation, regardless of subtype, and should generally be resected. In particular, βex3-HA carries a high risk of malignant transformation and can be considered a true precancerous lesion.

CONCLUSION

The management of HAs is based on a multidisciplinary approach. Clinical decision-making should integrate information on gender, tumor size, and HA subtyping. In the future, patients with HA will benefit from novel medical therapies tailored to the individual molecular subtypes.

Spontaneous idiopathic liver hemorrhage: a systematic review of a rare entity

BACKGROUND

Spontaneous idiopathic liver hemorrhage (SILH) is a rare life-threatening condition occurring without a clear and specific etiology. A systematic review was performed to provide guidelines for the perioperative management of patients affected by SILH. A case report was also included.

METHODS

A systematic search of the last 24-year literature was conducted and the manuscript was structured following point-by-point the PRISMA guidelines.

RESULTS

After an initial selection of 6995 titles, 15 articles were considered for the final qualitative analysis (n = 22 patients, including the present report). Conservative treatment was chosen in 12 cases (54.5%) with stable clinical conditions, while 9 patients (40.9%) required a primary operative approach for emergency presentation at diagnosis. Direct liver resection was the preferred surgical treatment (n = 6), mostly major hepatectomies (n = 4). Hepatic arterial embolization was performed as the primary operative approach in three patients, followed by emergency laparotomy during the same hospitalization because of rebleeding in one case. Contrast-enhanced CT scan was the gold standard for diagnosis (n = 19).

CONCLUSIONS

Conservative treatment of SILH is mainly based on stable clinical conditions and may be considered even in case of a limited arterial blush found on imaging. The absence of underlying hepatic or systemic disorders seems to correlate with favorable outcomes and no mortality.

Spontaneous Hepatic Hemorrhage: An Unexpected Complication From Enoxaparin

Spontaneous hepatic hemorrhage (SHH) is a rare condition that occurs due to a breach in the liver parenchyma in the absence of an external cause, most commonly from hepatocellular cancer. If a solid liver lesion is absent, then it has been linked with diffuse hepatic diseases or systemic diseases. Although SHH has been linked with the use of warfarin, it has not been thus far linked with enoxaparin. SHH can present with non-specific symptoms, and lab parameters can reveal substantial drops in hemoglobin. It is diagnosed most commonly with computed tomography (CT) imaging and conservative treatment is effective in the majority of cases. We present one such rare case of SHH.

Emergencies in paediatric hepatology

The aetiology of several liver diseases in children is age specific and many of these conditions have significant and potentially long-term clinical repercussions if not diagnosed early and managed in a timely fashion. We address 5 clinical scenarios that cover most of the diagnostic and therapeutic emergencies in children: infants with liver disease; acute liver failure; management of bleeding varices; liver-based metabolic disorders; and liver tumours and trauma. A wide spectrum of conditions that cause liver disease in infants may present as conjugated jaundice, which could be the only symptom of time-sensitive disorders - such as biliary atresia, metabolic disorders, infections, and haematological/alloimmune disorders - wherein algorithmic multistage testing is required for accurate diagnosis. In infantile cholestasis, algorithmic multistage tests are necessary for an accurate early diagnosis, while vitamin K, specific milk formulae and disease-specific medications are essential to avoid mortality and long-term morbidity. Management of paediatric acute liver failure requires co-ordination with a liver transplant centre, safe transport and detailed age-specific aetiological work-up - clinical stabilisation with appropriate supportive care is central to survival if transplantation is indicated. Gastrointestinal bleeding may present as the initial manifestation or during follow-up in patients with portal vein thrombosis or chronic liver disease and can be managed pharmacologically, or with endoscopic/radiological interventions. Liver-based inborn errors of metabolism may present as encephalopathy that needs to be recognised and treated early to avoid further neurological sequelae and death. Liver tumours and liver trauma are both rare occurrences in children and are best managed by a multidisciplinary team in a specialist centre.

Ruptured Hepatocellular Carcinoma: Current Status of Research

Background

Ruptured hepatocellular carcinoma (rHCC) is considered a rare and life-threatening manifestation; when it happens, it often requires acute and positive intervention. At present, the mechanism of rHCC development is gradually being understood while there are many kinds of rHCC treatment. From our clinical observation, the prognosis of rHCC patients is not as poor as it is currently believed. It may not be appropriate to include all patients with rHCC in T4.

Main Body

The incidence of ruptured hepatocellular carcinoma is now rising. Especially in the Asian region, it can even reach 10% – 15%. The most common symptom of HCC rupture is abdominal pain, and there are now a variety of treatments for hepatocellular carcinoma rupture. With aggressive treatment, rHCC patients can also achieve a better prognosis. The patient’s condition varies on admission, so the treatment methods will also be different. It is critical to identify prognostic factors simultaneously, and rHCC can be effectively managed by focusing on important prognostic factors.

Conclusion

A review was carried out to analyze diagnosis, mechanism, treatment, and prognostic risk factors on this disease condition during the current situation; it is hoped that it will provide better guidance for clinicians. Moreover, patients with rHCC were managed hierarchically to prolong their prognosis.

A systematic review on the complications and management of hepatic adenomas: a call for a new approach

Hepatic adenomas are benign hepatic lesions with heterogeneous characteristics. Awareness of complications, including haemorrhage and malignant transformation, has improved alongside a concurrent rise in their detection. Monitoring and management guidelines, however, remain inconsistent. This systematic review analyses the natural history of hepatic adenomas, and existing and novel risk factors associated with haemorrhage and malignant transformation. Results of this systematic review commonly identified male sex, and the beta-catenin histopathological hepatic adenoma subtype, as risk factors for malignant transformation, whilst those associated with haemorrhage included lesion size and number, exophytic nature, and recent hormone use. Overall, females demonstrated higher rates of haemorrhage, whilst males exhibited a higher risk of hepatocellular carcinoma development. This systematic review highlights that tumour size and subtype may not be as characteristically linked with complications as previously thought. We have additionally reported novel risk factors contributing to development of hepatic adenoma-related complications. We conclude by highlighting the risk of taking a conservative approach to seemingly low-risk lesions and suggest revised practice guidelines.

Acute hemoperitoneum after ruptured hepatocellular carcinoma: First Moroccan SCARE-compliant case report and literature review

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Acute hemoperitoneum after a spontaneously ruptured hepatocellular carcinoma (HCC) is a rare complication.

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In cases with stable conditions, imaging guided by computed tomography (CT) enables arterial embolisation.

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Surgery is a choice after failure of embolisation or in case of severe hemodynamic instability.

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The prognostic outcomes of ruptured HCC depend mostly on the underlying liver function.

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Successful management by one-stage surgery allowed radical treatment of this rare entity.

Introduction

Acute hemoperitoneum with a spontaneously ruptured hepatocellular carcinoma (HCC) is a rare type of internal bleeding that requires a multidisciplinary management approach.

Presentation of case

In this case report, we describe a fortuitously ruptured peripheral and discovered HCC in an 81-years-old woman treated effectively using hepatectomy.

Discussion

The use of the computed tomography (CT) angiography to diagnose the stability of the patient’s condition allows both arterial embolization in case of active bleeding and the evaluation of the underlying hepatopathy. The place of surgery is particularly upon after both the failure of arterial embolization and while facing a severe hemodynamic instability. The surgical strategy varies between perihepatic tamponnade and a surgical resection in one or more stages. The prognosis of a ruptured HCC depends mainly on the underlying liver’s function.

Conclusion

Multidisciplinary management of spontaneously ruptured HCC results in the same survival outcome as non-ruptured HCC at the same stage of hepatopathy.

Hemoperitoneum caused by spontaneous rupture of hepatocellular carcinoma in noncirrhotic liver. A case report and systematic review

INTRODUCTION

Hepatocellular carcinoma (HCC) is the sixth most common cancer. Spontaneous rupture of HCC is an acute complication with a high mortality rate. The HCC principally arises in the background of chronic liver disease and cirrhosis of the liver. In the last few years, the rising incidence of HCC in noncirrhotic liver suggests the presence of other factors that may play a role in liver carcinogenesis.

METHODS

We reviewed all cases treated at the University Surgical Department of Ospedali Riuniti of Foggia from 2009 to 2018. Only a single case of hemoperitoneum caused by spontaneous rupture of HCC in noncirrhotic liver was found. An extensive search of the relevant literature was carried out using MEDLINE, and a total of 58 published studies were screened from the sources listed.

CONCLUSIONS

The management of this devastating emergency should be carefully analyzed, with stabilization of vital signs as soon as possible. Patient with ruptured HCC and hemoperitoneum without a prior history of cirrhosis and viral infections benefited from the role of transcatheter arterial embolization (TAE) as the preliminary treatment in order to have a more precise diagnosis and an optimal stabilization of the patient. Delayed or staged hepatectomy after TAE represents the definitive treatment.

Transcatheter arterial embolization in hepatic tumor hemorrhage

Objective: Spontaneous hepatic tumor hemorrhage is a rare but challenging emergency especially among cirrhotic patients with poor hepatic function. This study aimed at analyzing the safety, efficacy and feasibility of transcatheter arterial embolization (TAE) in the treatment of hepatic tumor hemorrhage. Methods: This retrospective study included all patients undergoing embolization attempt for hepatic tumor hemorrhage in the Helsinki University Hospital during 2004-2017. Electronic medical records provided the study data. Outcomes included the 30-day rebleeding, complication and mortality rates, need for blood transfusions, durations of intensive care unit and hospital admissions, estimates of overall survival, and analysis of factors associated with 30-day mortality. Results: During the study period, 49 patients underwent angiography for hepatic tumor hemorrhage. TAE was technically feasible in 45 patients (92%), and controlled the bleeding with the first attempt in 84%. The 30-day complication and mortality rates were 57 and 33%, respectively. Major complications occurred in 33% of patients. In-hospital mortality was higher among cirrhotic than non-cirrhotic patients (55 versus 7%, p < .001). Patients with bleeding hepatic metastases, but no cirrhosis, had an in-hospital mortality of 0% with no major complications. Patients with benign etiology had a good prognosis and no bleeding- or tumor-related mortality. Discussion: TAE is an effective method in controlling the bleeding in spontaneous hepatic hemorrhage. Underlying pathology determines the prognosis that is poor especially in cirrhotic patients with bleeding hepatocellular carcinoma.

Intratumoral Hemorrhage of Liver Metastasis from a Rectal Neuroendocrine Tumor

A 56-year-old healthy woman was referred to our hospital for abdominal pain. Contrast-enhanced computed tomography (CT) showed a 14-cm-diameter liver tumor with intratumoral hemorrhage. We performed emergent transcatheter arterial embolization. She was referred to hepatic surgeon (M.M.) for resection. Preoperative colonoscopy showed an elevated lesion measuring 2 cm in diameter that was pathologically diagnosed as a rectal neuroendocrine tumor (NET). We performed low anterior resection of the rectum, followed by extended right hepatectomy for all hepatic lesions. Intratumoral hematoma was observed in the largest hepatic lesion (size: 150 mm×100 mm). Microscopy also indicated NET G2. We pathologically diagnosed a liver tumor from a rectal NET that bled spontaneously.

Amniotic fluid embolism and spontaneous hepatic rupture during uncomplicated pregnancy: a case report and literature review

Amniotic fluid embolism (AFE) and spontaneous hepatic rupture both are extremely rare complications of pregnancy that can be fatal to mother and/or child. AFE is characterized by a sudden collapse of the cardiovascular system, a change in mental status, and disseminated intravascular coagulation (DIC), occurring immediately during labor, delivery, or postpartum, caused by the inflow of amniotic components into the maternal circulation. Spontaneous hepatic rupture during pregnancy which is most often occurs alongside hypertensive disorders, eclampsia, or HELLP syndrome. We report on the case of a 28-year-old woman (G3P2) who is suffering from AFE and spontaneous hepatic rupture, without history of hypertensive disorders, preeclampsia/eclampsia, or HELLP syndrome, and she died suddenly after delivering of a severe asphyxial neonate within 1 h with postpartum of hepatic rupture and massive hemorrhage. The lack of typical clinical signs and symptoms resulted to the difficulty of early diagnosis. If AFE and hepatic rupture is highly suspected in a pregnant patient, a collaborative multidisciplinary approach is mandatory. Pregnancy women is simultaneously complicated in amniotic fluid embolism and spontaneous hepatic rupture, similar cases are infrequent in the literature, which is reviewed in this report, explore the pathophysiological changes, we hope that can be helpful for the prevention, diagnosis and treatment of similar cases.

Pancreaticoduodenal arcades as salvage route for transarterial embolization of life-threatening hepatic hemorrhage in patients with severe celiac axis stenosis: Case series

INTRODUCTION

Various transarterial embolotherapies for different hepatic etiologies are performed through the celiac axis (CA). However, this pathway is not always patent due to the extensive stenosis or occlusion of the origin of CA. In such situations, the pancreaticoduodenal arcades (PDAs) catheterization is the main alternative to gain access to the hepatic arteries as demonstrated in clinical studies.

PRESENTATION OF CASE

We report two cases of life-threating hepatic hemorrhage indicated for emergency transarterial embolization (TAE).

DISCUSSION

The massive hemorrhage was due to spontaneous rupture of hepatocellular carcinoma (HCC) in the first case and due to post liver blunt trauma in the second case. Owing to severe stenosis of the origin of CA, PDAs were used as a salvage alternative route for emergency TAE of hepatic arteries.

CONCLUSION

Endovascular management of massive hepatic hemorrhage in cases of inaccessibility to hepatic arteries through CA is a highly challenging situation in which the technical success depends on the operator experience, choice of the material and anatomical knowledge of hepatic arterial collateral supply.

Retracted: Systematic review: benefits and harms of transarterial embolisation for treating hepatocellular adenoma

The above article1 from Alimentary Pharmacology & Therapeutics, published online on 20 March 2017 in Wiley OnlineLibrary (www.onlinelibrary.wiley.com) has been retracted by agreement between the Authors, the Editor-in-Chief, R.E. Pounder, and John Wiley & Sons Ltd. The retraction has been agreed due to the inclusion of data accessible only during peer review for another journal.

Systematic review of transarterial embolization for hepatocellular adenomas

Background

Hepatocellular adenoma (HCA) larger than 5 cm in diameter is considered an indication for elective surgery, because of the risk of haemorrhage and malignant transformation. Transarterial embolization (TAE) is used to manage bleeding HCA and occasionally to reduce tumour size. TAE might have potential as an elective therapy, but its current role in this context is uncertain. This systematic review provides an overview of clinical outcomes after TAE, in bleeding and non-bleeding HCA.

Methods

Two independent reviewers performed a systematic search of literature in PubMed and Embase. Outcomes were change in tumour size, avoidance of surgery, complications and malignant transformation after TAE in bleeding and non-bleeding HCA. The Critical Appraisal Skills Programme tool for cohort studies was used for quality assessment of included studies.

Results

From 320 potential articles, 20 cohort studies and 20 case reports including 851 patients met the inclusion criteria. TAE was performed in 151 of 851 patients (17·7 per cent), involving 196 tumours, of which 95 (48·5 per cent) were non-bleeding. Surgical treatment was avoided in 68 of 151 patients (45·0 per cent). Elective TAE was performed in 49 patients involving 66 HCAs, with 41 of these patients (84 per cent) not requiring surgery. Major complications occurred in eight of 151 patients (5·3 per cent); no death was reported. Among cohort studies, complete tumour disappearance was observed in 10 per cent of patients, and regression in 75 per cent.

Conclusion

Acute or elective TAE in the management of HCA is safe. In the elective setting, TAE provides a potential alternative to surgery.

Liver radiofrequency ablation as emergency treatment for a ruptured hepatocellular carcinoma: a case report

BACKGROUND

Hemoperitoneum is a possible complication of hepatocellular carcinoma that may require emergency surgery as an alternative to radiological locoregional therapies.

CASE PRESENTATION

We present a case report of a 78-year-old white man with alcoholic-related cirrhosis and a multifocal hepatocellular carcinoma. An abdominal computed tomography scan showed multiple and bilateral foci of bleeding from broken liver cancer. He was urgently transferred from our radiology unit to our operating room for massive hemoperitoneum. A middle line laparotomy detected a massive hemoperitoneum. His liver was cirrhotic and completely subverted by a tumor; there were two spontaneous bleeding lacerations on segments II and IV, which were uncontrollable with conventional hemostatic techniques. Therefore, it was decided to carry out the coagulation of the multiple vascular afferents of each single mass by means of radiofrequency ablation cycles performed circumferentially on both nodules for a total of 40 minutes. Hemostasis was achieved; the radiofrequency ablation controlled the bleeding from his ruptured hepatocellular carcinoma. He was transferred to our intensive care unit for postoperative monitoring in terms of hemodynamic stability. On postoperative day 2 he was discharged from our intensive care unit.

CONCLUSIONS

Multifocal bleeding hepatocellular carcinoma still has an extremely high mortality. The angiographic control of multiple bilateral bleeding lesions can be extremely difficult and can be contraindicated by the location of the lesions and by the overall clinical condition of the patient. In this case, treatment with radiofrequency ablation has proven to be effective in the control of multiple and bilateral hepatic lesions. This particular technique allowed us to attack the lesion at the level of the vascular pedicle in order to control the bleeding.

Congenital afibrinogenemia: a case report of a spontaneous hepatic hematoma

INTRODUCTION

Afibrinogenemia is a rare coagulation disorder. Clinical features of spontaneous bleeding, bleeding after minor trauma, or after surgery have been described as well as thrombo-embolic complications. In this article, we presented the case of a 19-year old female with congenital afibrinogenemia who was admitted with a spontaneous intrahepatic hematoma.

CONCLUSIONS

Supportive treatment including transfusion and fibrinogen administration, associated with repeated packing surgeries and selective embolization, were successfully performed.

Treatment of Hepatic Adenomatosis

Hepatic adenomatosis and hepatocellular adenomas share risk factors and the same pathophysiologic spectrum. The presence in the liver of 10 hepatocellular adenomas defines hepatic adenomatosis. The diagnosis may be established incidentally during a liver radiologic examination in the asymptomatic patient, or after associated right upper quadrant pain, hepatomegaly or liver test abnormalities. Upon the diagnosis of hepatic adenomatosis or either of its life-threatening complications - hemorrhage and progression to hepatocellular carcinoma - consideration should be given to potential medical, radiologic and surgical interventions including: observation (estrogens and androgens withdrawal), resection, transarterial embolization, radiofrequency ablation and liver transplantation. The management of patients with hepatic adenomatosis can be challenging. These patients should be ideally referred to centers with expertise in the management of liver diseases.

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.

Management of Hepatocellular Adenoma: Recent Advances

Hepatocellular adenoma (HCA) is a rare benign liver cell neoplasm that occurs more frequently in young women with a history of prolonged use of oral contraceptives. Surgical resection is considered because of the risk of hemorrhage in 25% and of malignant transformation in 5% of patients with HCA. HCA is a heterogeneous disease comprising 3 subtypes with distinct molecular and complication profiles. The inflammatory or telangiectatic subtype is at increased risk for hemorrhage, the β-catenin-activated subtype is at increased risk for malignant transformation, and the hepatocyte nuclear factor-1α-inactivated or steatotic subtype is at the least risk for complications. One-third of the patients with HCA have multiple tumors on imaging with no increased risk of complications. Magnetic resonance imaging is the modality of choice for the diagnosis and subtype characterization of HCA. Systematic resection of HCA is recommended in male patients owing to the higher incidence of malignant transformation, and surgical excision in women should be reserved for tumors 5 cm or larger associated with an increased risk of complications. Cessation of hormonal therapy and radiologic surveillance in women with HCA tumors smaller than 5 cm shows that the vast majority of HCA remain stable or undergo spontaneous regression. Percutaneous core needle biopsy is of limited value because the therapeutic strategy is based primarily on patient sex and tumor size. Transarterial embolization is the initial treatment for HCA complicated by hemorrhage. Pregnancy should not be discouraged in the presence of HCA, however, frequent sonographic surveillance is recommended.

Resection, transplantation and local regional therapies for liver adenomas

Hepatocellular adenoma (HCA) is a rare benign liver-cell neoplasm, occurring predominantly in young obese women using oral contraceptives. HCA is a heterogeneous disease, which includes four subtypes (including unclassified) associated with various risks of haemorrhagic complications and malignant transformation. Magnetic resonance imaging is the modality of choice for both diagnosis and subtype characterization of HCA whereas percutaneous biopsy has only limited impact on the therapeutic strategy. In men HCA should be always resected while in women surgery should only be considered for lesions ≥5 cm and after cessation of hormonal therapy. Women with single or multiple HCAs <5 cm may be followed with regular MRI imaging since the vast majority of HCA remains stable or decreases in size. Pregnancy should not be discouraged provided close sonographic surveillance is undertaken.

Management of bleeding liver tumors

Liver tumors bleed rarely; management has changed radically during the last 20years, advancing from emergency surgery with poor results to multidisciplinary management. The first steps are the diagnosis and control of bleeding. Abdominopelvic CT scan should be performed as soon as patient hemodynamics allow. When active bleeding is visualized, arterial embolization, targeted as selectively as possible, is preferable to surgery, which should be reserved for severe hemodynamic instability or failure of interventional radiology. When surgery is unavoidable, abbreviated laparotomy (damage control) with perihepatic packing is recommended. The second step is determination of the etiology and treatment of the underlying tumor. Adenoma and hepatocellular carcinoma (HCC) are the two most frequently encountered tumors in this context. Liver MRI after control of the bleeding episode generally leads to the diagnosis although sometimes the analysis can be difficult because of the hematoma. Prompt resection is indicated for HCC, atypical adenoma or lesions at risk for degeneration to hepatocellular carcinoma. For adenoma with no suspicion of malignancy, it is best to wait for the hematoma to resorb completely before undertaking appropriate therapy.