Imaging Pearls ❯ Liver ❯ Liver Bleeds
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- Tumor rupture can be spontaneous, iatrogenic or happen because of trauma. The rupture of a malignant tumor is a serious emergency, and, in some cases, it can cause up to 75% mortality. Several mechanisms have been proposed to explain the spontaneous rupture of a tumor. Disruption of the tumor surface due to rapid growth, neovascularization, tear in a feeding artery or increased intratumoral pressure as a result of venous occlusion by tumor cells are some of the theories. Tumor rupture happens more frequently in tumors with higher vascularity like hepatocellular carcinoma (HCC) and renal cell carcinoma (RCC).
Imaging of abdominopelvic oncologic emergencies.
Pooyan A, Mansoori B, Wang C.
Abdom Radiol (NY). 2023 Nov 28. doi: 10.1007/s00261-023-04112-8. Epub ahead of print. PMID: 38017112. - “Spontaneous rupture of HCC complicates up to 15% of the cases. Larger HCCs (>5cm) and lesions that are located in the peripheral or subcapsular location have a higher risk of rupture. Other known risk factors include hypertension and post treatment settings like after transarterial chemoembolization (TACE). In the case of an acutely ruptured HCC, US shows an echogenic/cirrhotic liver and adjacent free fluid/hemoperitoneum (usually heterogenous echogenicity). CT shows areas of high attenuation hematoma (45-70 HU) in the vicinity of the organ. Several studies show that both hypo- and hypervascular liver metastasis could bleed spontaneously.”
Imaging of abdominopelvic oncologic emergencies.
Pooyan A, Mansoori B, Wang C.
Abdom Radiol (NY). 2023 Nov 28. doi: 10.1007/s00261-023-04112-8. Epub ahead of print. PMID: 38017112.
- Causes of Spontaneous Bleeds: Liver
- Hepatoma
- Hepatic adenoma
- Focal nodular hyperplasia
- Metastases (NET, RCC, melanoma)
- Hepatic angiosarcoma
- Hepatoblastoma - "Hepatic angiosarcoma (HA), albeit rare, is the most common malignant mesenchymal tumor of the liver and accounts for 2% of all primary liver tumors. Exposure to thorotrast, vinyl chloride, arsenic, anabolic steroids, and radiation have all been mentioned in etiopathogenesis. It is more common in males and mostly seen in the sixth or seventh decades of life. HAs are biologically very aggressive and often metastatic at the initial diagnosis. Lungs and spleen are the most common sites for metastases. On gross pathological evaluation, the tumor is characterized by remarkable necrosis and intratumoral bleeding.”
Imaging findings of spontaneous intraabdominal hemorrhage: neoplastic and non‐neoplastic causes
Sevtap Arslan et al.
Abdominal Radiology (2022) 47:1473–1502 - "Although the most common cause of spontaneous hepatic hemorrhage in patients with cirrhosis is HCC rupture, spontaneous hepatic hemorrhage without malignant changes may also be rarely seen in cirrhosis. The underlying mechanism is either the rupture of macronodular cirrhosis or rupture of the lymphatic vessels and varicose veins due to portal hypertension. Extreme caution should be exercised in these patients not to overlook an underlying HCC.”
Imaging findings of spontaneous intraabdominal hemorrhage: neoplastic and non‐neoplastic causes
Sevtap Arslan et al.
Abdominal Radiology (2022) 47:1473–1502
- “The spectrum of postpartum complications ranges from relatively self-limiting to life-threatening conditions that can be divided into six categories: infectious conditions (endometritis), thrombotic complications (eg, deep vein thrombosis, ovarian vein thrombophlebitis, HELLP [hemolysis, elevated liver enzymes, and low platelet count] syndrome, or cerebral sinus thrombosis), hemorrhagic conditions (eg, uterine atony, trauma of the lower portion of the genital tract, retained products of conception, uterine artery arteriovenous malformations, or uterine artery pseudoaneurysm), cesarean delivery–related complications (eg, bladder flap hematoma, subfascial hematoma, rectus sheath hematoma, abscess formation, uterine dehiscence, uterine rupture, vesicovaginal fistula, or abdominal wall endometriosis), iatrogenic conditions (eg, uterine perforation), and nonobstetric complications (eg, acute cholecystitis, acute appendicitis, uterine fibroid degeneration, renal cortical necrosis, pyelonephritis, posterior reversible encephalopathy syndrome, or pituitary gland apoplexy).”
A Pictorial Review of Postpartum Complications
Marta Gonzalo-Carballes et al.
RadioGraphics 2020; 40:2117–2141 - “HELLP syndrome is a life threatening condition that occurs in 0.2%–0.8% of pregnancies (37). It typically develops in patients with severe preeclampsia (70%–80% of cases) and usually manifests between 32 and 34 weeks of gestation. However, up to 30% of cases manifest in the postpartum period, usually within 48 hours after delivery. This condition is associated with high maternal and perinatal morbidity and mortality.”
A Pictorial Review of Postpartum Complications
Marta Gonzalo-Carballes et al.
RadioGraphics 2020; 40:2117–2141 - “The etiology and pathophysiologic manifestations of HELLP syndrome are incompletely understood. Endothelial dysfunction leads to activation of intravascular coagulation, with fibrin deposition in the capillaries. Consequently, multiple microcirculation disorders take place. Histopathologic analysis of the liver shows fibrin deposition in the hepatic sinusoids that can lead to progressive obstruction of the blood flow, periportal hemorrhage, and hepatocellular necrosis.”
A Pictorial Review of Postpartum Complications
Marta Gonzalo-Carballes et al.
RadioGraphics 2020; 40:2117–2141 - “Clinical manifestations are variable and include epigastric or right upper quadrant pain, nausea, and vomiting. The classic symptoms of preeclampsia, hypertension, and proteinuria may be minimal or absent. The diagnosis of HELLP syndrome is based on both clinical and biochemical features. The contribution of imaging is confirmation of the diagnosis and assessment for complications.”
A Pictorial Review of Postpartum Complications
Marta Gonzalo-Carballes et al.
RadioGraphics 2020; 40:2117–2141 - “CT is the modality of choice for evaluating patients with HELLP syndrome who are in unstable condition, because active bleeding and hepatic rupture are better shown with this technique. Hepatic hematoma and hepatic infarction are also properly evaluated with contrast-enhanced CT.”
A Pictorial Review of Postpartum Complications
Marta Gonzalo-Carballes et al.
RadioGraphics 2020; 40:2117–2141 - “Postpartum hemorrhage is one of the leading causes of maternal mortality; the death rate due to this cause is high in lower-income countries. Several studies have reported an increasing trend in the incidence of postpartum hemorrhage in high-income countries. Postpartum hemorrhage is classified as primary when it occurs within the first 24 hours after delivery and secondary when it develops between 24 hours and 12 weeks after delivery.”
A Pictorial Review of Postpartum Complications
Marta Gonzalo-Carballes et al.
RadioGraphics 2020; 40:2117–2141 - “The postpartum period is a clearly defined physiologic state, and knowledge of its anatomic and pathophysiologic particularities is crucial for an accurate diagnosis when complications arise. A familiarity with the typical appearance of the postpartum anatomy as it is seen with different imaging techniques enables correct differentiation of the substantially overlapping normal and abnormal postpartum radiologic findings. In many cases, these findings are almost indistinguishable, making the patient’s clinical history the defining element. Communication with the patient is a cornerstone for accurate diagnosis and proper treatment.”
A Pictorial Review of Postpartum Complications
Marta Gonzalo-Carballes et al.
RadioGraphics 2020; 40:2117–2141 - Hepatic Bleeds: Etiology
- hepatocellular carcinoma
- hepatic adenoma
- other liver tumors, such as focal nodular hyperplasia, hemangiomas, and metastases
- HELLP syndrome
- Amyloidosis
- connective tissue diseases such as polyarteritis nodosa and systemic lupus erythematosus
- infectious diseases such as typhoid fever, and parasitic diseases such as malaria - “The most common causes of nontraumatic hepatic hemorrhage are hepatocellular carcinoma and hepatic adenoma. Such hemorrhage can also occur in patients with other liver tumors, such as focal nodular hyperplasia, hemangiomas, and metastases. Other conditions associated with this entity include HELLP syndrome, amyloidosis, and miscellaneous causes.”
Imaging of Nontraumatic Hemorrhagic Hepatic Lesions
V. Javier Casillas et al.
RadioGraphics 2000; 20:367–378 - “HELLP syndrome was described by Weinstein in 1982. A small subset of preeclamptic or eclamptic women presented with findings of hemolysis, elevated liver enzymes, and low platelet count. This constellation of findings is known as the HELLP syndrome. This serious obstetric condition, which occurs either before or immediately after birth, may progress rapidly with complications including disseminated intravascular coagulation, hepatic necrosis, and hemorrhagic infarction.”
Imaging of Nontraumatic Hemorrhagic Hepatic Lesions
V. Javier Casillas et al.
RadioGraphics 2000; 20:367–378