Via Research Recognition Day Program VCOM-Carolinas 2025

Case Reports

Hemorrhagic Rupture of a Hepatic Adenoma in a Postmenopausal Female: A Case Report Rebecca Corallo, OMSIII, Carrie Watson, DO, FACOS, FACS. 1. Piedmont Medical Center, Rock Hill, SC. 2. Edward Via College of Osteopathic Medicine - Carolinas, Spartanburg, SC.

Abstract

Case Report Continued

Discussion

References 1. Klompenhouwer, A. J., Sprengers, D., Willemssen, F. E., Gaspersz, M. P., Ijzermans, J. N., & De Man, R. A. (2016). Evidence of good prognosis of hepatocellular adenoma in post-menopausal women. Journal of Hepatology , 65 (6), 1163 – 1170. https://doi.org/10.1016/j.jhep.2016.07.047 2. Kyvetos, A., Voukelatou, P., Vrettos, I., Pantzios, S., & Elefsiniotis, I. (2023). A Case Report on a Giant Hepatic Inflammatory Adenoma in a Young Female That Presented as Spontaneous Intrahepatic Hematoma. Cureus , 15 (7), e42055. https://doi.org/10.7759/cureus.42055 3. Mathew, R. P., Manolea, F., Girgis, S., Patel, V., & Low, G. (2019). Malignant transformation of hepatic adenoma complicated by rupture and hemorrhage: An extremely rare clinical entity. Intractable & rare diseases research , 8 (4), 266 – 270. https://doi.org/10.5582/irdr.2019.01089 4. Oldhafer, K. J., Habbel, V., Horling, K., Makridis, G., & Wagner, K. C. (2020). Benign Liver Tumors. Visceral medicine , 36 (4), 292 – 303. https://doi.org/10.1159/000509145 5. Shreenath AP, Grant LM, Kahloon A. Hepatocellular Adenoma. [Updated 2024 May 6]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-.Available from: https://www.ncbi.nlm.nih.gov/books/NBK513264/ complication across all age groups. While spontaneous regression of HA following menopause is documented, this case emphasizes the need to maintain vigilance for HA rupture in older females, especially when imaging findings align with potential risk factors. Conclusions This case examined a postmenopausal female that faced a potentially fatal complication of a rare disease process. The aim of this report is to increase recognition of HA rupture as a potentially fatal menopause, due to reduced estrogen stimulation, thereby lowering the risk of rupture and complicating the likelihood of rupture in this patient. 1 • HAs are typically asymptomatic and are often diagnosed incidentally through imaging studies or when complications, such as hemorrhage, arise. 4, 5 o Imaging modalities including US, contrast CT, or MRI are commonly utilized. If results are inconclusive, a biopsy may be considered as an alternative diagnostic approach. 1, 3 • Unlike this case, HA rupture is most frequently observed in premenopausal females aged 28-37, particularly with lesions larger than 5 cm and associated with risk factors, including obesity, steroid use, and OCPs. 1, 2, 4 • Although rare, malignant transformation of HA into hepatocellular carcinoma has been reported. This complication is more commonly seen in postmenopausal females aged 48-68. 1 • As demonstrated in this patient, the management of HA is typically conservative, emphasizing risk factor modification and observation, especially for lesions smaller than 5 cm. 1, 2, 4 o Surgical intervention is recommended for lesions exceeding 5 cm or for those that persist or grow despite conservative measures. 2, 4 o Unlike most reported cases, this patient's lesion did not regress despite conservative management. If subsequent imaging continues to demonstrate no change in size, surgical intervention may be considered. • The diameter of HAs tend to decrease significantly following

Hepatic adenoma (HA) is a rare benign liver lesion typically observed in females of reproductive age, often associated with oral contraceptive pill (OCP) use. While typically asymptomatic, HA can result in severe complications, including hemorrhage. Current literature highlights an increased risk of hemorrhage in larger lesions among premenopausal females, with the most common complication in postmenopausal females being malignant transformation to hepatocellular carcinoma. This report discusses a case of a postmenopausal female who presented with sudden onset back pain, ultimately diagnosed with hemorrhage of HA following imaging and surgical intervention. This case aims to increase recognition of HA hemorrhage as a potentially fatal complication that can occur across all age groups. Epidemiology : 3, 4, 5 • More common in females than males, ratio of 4 to 1 • Annual HA incidence among patients taking OCPs: 3 to 4 per 100,000 • Annual HA incidence among patient not taking OCPs: 1 per 100,000 Risk Factors : 3, 4, 5 • OCP • Exogenous steroids Management : 5 • Obesity • Glycogen storage diseases Background Complications : 5 • Hemorrhage: 27% of HA , more likely in HA > 5cm • Malignant transformation: higher risk in males compared to females, HAs > 5cm, and postmenopausal females Case Report A 58-year-old postmenopausal female with normal BMI presented to the ED after two episodes of syncope with nausea, vomiting, and diarrhea, following sudden right-sided back pain. She denied fevers, chills, urinary symptoms, or vaginal bleeding. Medical history included OCP use for menopausal symptoms. Initial management was with IV fluids and antiemetics with presumed diagnosis of nephrolithiasis. CT imaging revealed hemoperitoneum and a hyperdense liver nodule on the right lobe. Labs revealed a hemoglobin (Hgb) of 8.6. • Males: resection in lesions of all size • Females: resection in lesions > 5cm o Lesions < 5cm: conservative management

Diagnostic laparoscopy was performed to explore potential gynecologic bleeding. Surgery didn’t reveal ruptured ovarian cysts or intra-abdominal injuries. The hemoperitoneum was evacuated and a ruptured lesion was identified on the liver’s right lobe. The lesion was left undisturbed given clot without active bleeding and Surgicel hemostatic powder was applied. Postoperatively, her Hgb dropped to 6.6 and increased to 7.7 following a transfusion. Interventional radiology was consulted, and an MRI was performed to evaluate for possible angioembolization, which was not performed. MRI revealed a 3.8 cm right liver mass consistent with HA, no active bleeding. Figure 1. CT Abdomen and pelvis Depicts mass like density in the pelvis with large volume hyperdense peritoneal fluid and 4 cm nodule in the right lobe of the liver.

Figure 2. MRI Abdomen Depicts 3.8 cm mass of right liver consistent with HA.

The patient was discharged 3 days post-op with plans for follow up imaging and was advised to discontinue the use of OCPs. Repeat MRI 3 months post-op revealed a lesion of unchanged size despite cessation of OCPs. A follow up MRI has been scheduled for 6 months post-op.

Figure 3. MRI Abdomen Repeat imaging 3 months post-op of 3.8 cm right liver lesion.

2025 Research Recognition Day

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