SECTION EDITOR: CARL E. BREDENBERG, MD
Author Affiliations: Departments of Surgery (Drs Lyons and Conway) and Pathology (Dr Halat), Ochsner Medical Center, New Orleans, Louisiana.
A 32-year-old woman with no recent contraceptive use or significant medical history presented to the general surgery service at our center after experiencing 2 episodes of intra-abdominal hemorrhage. She denied any history of abdominal trauma.
Two weeks before presentation, the patient was seen at an outside hospital reporting severe posterolateral pain on the right side of the neck and mild generalized abdominal pain. Preliminary laboratory evaluation results revealed a hemoglobin level of 8.0 g/dL (to convert to grams per liter, multiply by 10) and an increased human chorionic gonadotropin level of 1500 mIU/mL (conversion to international units per liter is 1:1). The obstetrics department was consulted and diagnosed an ectopic pregnancy of approximately 5 weeks' gestation after transvaginal ultrasonography failed to show intrauterine products of conception. The patient was taken to the operating room for diagnostic laparoscopy, and 600 mL of blood was evacuated from her pelvis; no ectopic pregnancy was visualized. The patient was then discharged home. At follow-up 1 week later, the human chorionic gonadotropin level remained elevated at 1600 mIU/mL prompting treatment with methotrexate sodium.
Three days later, the patient returned to the emergency department with recurrent severe pain on the right side of the neck, worsening abdominal pain, and pain in the right shoulder. Laboratory evaluation results noted a drop in the hemoglobin level from the hospital discharge value of 9 g/dL to 6 g/dL, and she was given a 2-U transfusion of packed red blood cells. The patient was subsequently taken to the operating room for a second diagnostic laparoscopy and was again found to have a large amount of blood in her abdomen (1200 mL was evacuated). During this exploration, a view of the upper abdomen was obtained and revealed a large hematoma at the superior aspect of the liver near the inferior vena cava.
The surgery was aborted and a computed tomographic (CT) scan was obtained, which showed a large perihepatic clot (Figure 1). The patient was then transferred to our center.
Figure 1. An abdominal computed tomographic scan obtained at the referring hospital shows a large hematoma at the superior aspect of the liver (arrow).
A. Ruptured hepatic adenoma
B. Traumatic liver laceration
C. Ruptured ectopic pregnancy
D. Ruptured hepatic hemangioma
Neil Lyons, Shams Halat, W. Charles Conway. Image of the Month—Quiz Case. Arch Surg. 2012;147(10):975–975. doi:10.1001/archsurg.2011.1494a