A 60-year-old woman presented with a 4-week history of a right gluteal hematoma after a mild trauma associated with asthenia and unspecific upper abdominal symptoms. On physical examination, we observed ecchymoses in the flanks, buttocks, and lower limbs. Although abdominal palpation was normal, an ultrasound revealed a large heterogeneous mass of 10 × 7 cm in the left lateral segment of the liver. A contrast-enhanced computed tomogram showed a peripheral nodular pattern of enhancement with a hypodense center (Figure 1). The hematogram revealed anemia (hematocrit value, 19%; hemoglobin level, 9.9 g/dL) and thrombocytopenia (platelet count, 77× 103/μL). Coagulation tests showed the following values: fibrinogen, 400 mg/dL (11.8 μmol/L) (reference range, 150-400 mg/dL [4.4-11.8 μmol/L]); fibrin degradation products, 1.5 μg/mL (reference range, <0.5 μg/mL); and thrombin–antithrombin III complexes, 17.4 ng/mL (reference range, <5.0 ng/mL). All other biochemical characteristics were within normal limits.
Contrast-enhanced computed tomogram showing a giant heterogeneous mass (arrow) occupying the left segments of the liver.
The patient underwent laparotomy, and the mass was successfully removed without the need of intraoperative transfusions (Figure 2). The postoperative course was uneventful, and the patient was discharged on the fifth postoperative day.
Intraoperative picture showing an enucleated liver lesion from the surrounding normal hepatic parenchyma. Vessels at the transection plane were controlled with silk ligatures and titanium clips. The inlay image presents the resected well-capsulated tumor.
Rendu-Osler-Weber syndrome (hereditary hemorrhagic telangiectasia)
McCormack L, Petrowsky H, Clavien P. Image of the Month—Quiz Case. Arch Surg. 2007;142(4):399. doi:10.1001/archsurg.142.4.399