Imaging Pearls ❯ Liver ❯ Liver Hemorrhage
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- “A broad spectrum of pathologic conditions can present as spontaneous hemorrhage within or surrounding the liver and may present acutely or as a chronic or incidental finding. Imaging characteristics and clinical history can often narrow the differential diagnosis and guide management.”
Bleeding Liver Masses: Imaging Features With Pathologic Correlation and Impact on Management
Thomas AJ et al.
AJR 2019; 213:1–9 - “A broad spectrum of neoplastic and other pathologic conditions can result in hepatic hemorrhage. They have the potential for dev- astating consequences in cases of rupture, including hemorrhagic shock, abdominal compartment syndrome, and intraperitoneal tumor spillage. One can often narrow the differential diagnosis considerably by taking into account both the imaging features and aspects of the clinical history that may suggest a particular diagnosis.”
Bleeding Liver Masses: Imaging Features With Pathologic Correlation and Impact on Management
Thomas AJ et al.
AJR 2019; 213:1–9 - Bleeding Liver Masses: Differential Dx
- Hepatoma
- Hepatic metastases
- Hepatic angiosarcoma
- Hepatic adenoma
- Cavernous hemangioma
- Hepatic cyst
- Traumatic lesions - Bleeding Liver Masses: Differential Dx
- Hepatic artery aneurysm and pseudoaneurysm
- HELLP syndrome
- Peliosis
- Miss. Lesions (FNH, hepatoblastoma, cirrhosis without tumor) - “Patients often present with nonspecific clinical symptoms, such as pain, vomiting, and malaise. The hematoma can rupture into the subcapsular space of the liver, where it is contained between the liver and its capsule, resulting in an elliptic collection that com presses the liver . Subcapsular extension is more likely with peripherally located lesions. When it is no longer contained by the capsule, the hemorrhage can rupture into the peritoneal space. This can have devastating consequences, such as hemorrhagic shock and abdominal compartment syndrome.”
Bleeding Liver Masses: Imaging Features With Pathologic Correlation and Impact on Management
Thomas AJ et al.
AJR 2019; 213:1–9 - “Arterial phase imaging may reveal contrast extravasation, indicating active bleeding that may require urgent endovascular therapy. An ancillary sign of severe bleeding is flattening of the inferior vena cava, which can reflect hypovolemia or shock. In addition, periportal areas of low attenuation may result from aggressive fluid resuscitation.”
Bleeding Liver Masses: Imaging Features With Pathologic Correlation and Impact on Management
Thomas AJ et al.
AJR 2019; 213:1–9 - “The annual incidence of HCC in patients with cirrhosis is estimated at 2–8%, risk depending on the severity of the cirrhosis, underlying cause (viral hepatitis being the greatest risk), male sex, and coinfection with HIV.”
Bleeding Liver Masses: Imaging Features With Pathologic Correlation and Impact on Management
Thomas AJ et al.
AJR 2019; 213:1–9 - “Hepatocellular carcinoma (HCC) is the fifth most common malignancy in the world among men and the seventh most common among women. It is the second leading cause of cancer-related mortality. It is seen overwhelmingly in patients with cirrhosis, most often as a sequela of hepatitis B or hepatitis C. Other predisposing fac tors include alcohol abuse, nonalcoholic fatty liver disease, hemochromatosis, dietary exposure to aflatoxins, and α1-antitrypsin deficiency.”
Bleeding Liver Masses: Imaging Features With Pathologic Correlation and Impact on Management
Thomas AJ et al.
AJR 2019; 213:1–9 - “A frequent complication of these tumors is rupture with hemorrhage into the subcapsular or peritoneal space. Estimated to occur in 3–15% of cases, this complication is a cause of considerable morbidity and mortality. Although an underlying lesion may frequently be obscured or incompletely evaluated in patients with an acute bleed, a high index of suspicion should be maintained in the care of patients with cirrhosis and hepatic bleeding.”
Bleeding Liver Masses: Imaging Features With Pathologic Correlation and Impact on Management
Thomas AJ et al.
AJR 2019; 213:1–9 - “The cause of hemorrhage in HCCs is likely multifactorial and is not completely understood. Rupture may be facilitated by tumor angiogenesis, which increases as it mutates from a cirrhotic nodule to a dysplastic nodule to HCC. This leads to an increasing proportion of its vascular supply being derived from new, unpaired hepatic arteries with diminishing contributions from the portal venous system. Microinjuries and elastin deposition in these small arteries may predispose to hemorrhage.”
Bleeding Liver Masses: Imaging Features With Pathologic Correlation and Impact on Management
Thomas AJ et al.
AJR 2019; 213:1–9 - “Patients with HCC are often at increased baseline risk of bleeding due to underlying cirrhosis-associated coagulopathy. Although they are commonly spontaneous, hemorrhagic complications may also be precipitated by minor trauma or transarterial chemoembolization.”
Bleeding Liver Masses: Imaging Features With Pathologic Correlation and Impact on Management
Thomas AJ et al.
AJR 2019; 213:1–9 - Key features that predispose a particular tumor to rupture include its location within the liver and its size. The highest-risk tumors are large and within the periphery of the liver, either abutting or protruding beyond the capsule. The minimal thickness of peritumor liver parenchyma and the degree of capsular protrusion both have been associated with increased risk of rupture.
Bleeding Liver Masses: Imaging Features With Pathologic Correlation and Impact on Management
Thomas AJ et al.
AJR 2019; 213:1–9 - “However, several primary tumors cause hypervascular liver metastases, including neuroendocrine tumors, renal cell carcinoma, melanoma, choriocarcinoma, and sarcoma, which may increase the risk of bleeding.”
Bleeding Liver Masses: Imaging Features With Pathologic Correlation and Impact on Management
Thomas AJ et al.
AJR 2019; 213:1–9 - “Hepatic angiosarcoma, although very rare, is the third most common primary hepatic malignancy. It has been associated with a variety of environmental exposures, most notably thorium dioxide (Thorotrast, Testagar), arsenic, and polyvinyl chloride. It is most commonly seen in men in the sixth and seventh decades of life. It is highly aggressive and often metastatic at diagnosis; common sites include nearby structures, such as the spleen, stomach, and peritoneum, and distant sites, such as lungs, bone, and brain.”
Bleeding Liver Masses: Imaging Features With Pathologic Correlation and Impact on Management
Thomas AJ et al.
AJR 2019; 213:1–9 - “As an endothelial tumor, angiosarcoma is composed of abundant anastomosing vascular channels with regions of necrosis and blood-filled cysts. At imaging it can display one of several patterns, including a dominant mass, multiple nodules, or diffuse infiltrative tumor. Angiosarcoma is generally hypervascular and exhibits heterogeneous enhancement, potentially mimicking cavernous hemangioma. Rupture is a devastating complication of hepatic angiosarcoma. In addition to the dangers of the acute hemorrhage, spillage can cause peritoneal angiosarcomatosis and subsequent recurrent hemoperitoneum, which have a dismal prognosis.”
Bleeding Liver Masses: Imaging Features With Pathologic Correlation and Impact on Management
Thomas AJ et al.
AJR 2019; 213:1–9 - ”Resection of adenomas is generally considered once lesions reach a diameter greater than 5 cm, because the likelihood of rupture increases with lesion size. For patients who are not eligible for surgery, other options include embolization or percutaneous ablation, although this practice may evolve with advances in adenoma subtyping, potentially allowing more conservative management of lower-risk lesions.”
Bleeding Liver Masses: Imaging Features With Pathologic Correlation and Impact on Management
Thomas AJ et al.
AJR 2019; 213:1–9 - ”The inflammatory subtype is most common and has the greatest propensity for hemorrhage, approximately 20–25% displaying intratumoral hemorrhage. Other subtypes, including hepatocyte nuclear factor 1α (HNF-1α)−mutated adenomas, β-catenin– mutated adenomas, and unclassified subtype, are thought to carry lower risk of hemorrhage and rupture. Inflammatory adenomas have an approximately 10% chance of malignant transformation, which is less than in β-catenin–mutated adenomas but more than in HNF-1α–mutated tumors.”
Bleeding Liver Masses: Imaging Features With Pathologic Correlation and Impact on Management
Thomas AJ et al.
AJR 2019; 213:1–9 - ” Giant hemangiomas are generally well defined and have round or lobular margins. Compared with their smaller counterparts, giant hemangiomas often have a more complex imaging appearance that includes internal hemorrhage and areas of central necrosis, scarring, or calcification. Another potential complication of these large lesions is Kasabach-Merritt syndrome, a consumptive coagulopathy that, although more common in infants, can develop in adults. It has a mortality rate of 10–37%.”
Bleeding Liver Masses: Imaging Features With Pathologic Correlation and Impact on Management
Thomas AJ et al.
AJR 2019; 213:1–9 - “Aneurysms of the hepatic artery are the second most common visceral aneurysm, after splenic artery aneurysms. The most common cause is atherosclerosis, but aneurysms can also occur in vasculopathies such as fibromuscular dysplasia and polyarteritis nodosa and in patients with systemic infection, which can cause mycotic aneurysm. Pseudo- aneurysms more commonly result from trau- ma and liver transplant.”
Bleeding Liver Masses: Imaging Features With Pathologic Correlation and Impact on Management
Thomas AJ et al.
AJR 2019; 213:1–9 - ”Both aneurysms and pseudoaneurysms carry risk of rupture. Aneurysms are usually considered for elective repair if they are larger than 2 cm in diameter or are symptomatic. Pseudoaneurysms have a high propensity for bleeding and are generally repaired endovascularly regardless of size.”
Bleeding Liver Masses: Imaging Features With Pathologic Correlation and Impact on Management
Thomas AJ et al.
AJR 2019; 213:1–9 - ”HELLP syndrome (hemolysis, elevated liver enzyme levels, and low platelets) is a complication that occurs most often in the third trimester or soon after birth. It is associated with severe preeclampsia. It is thought to be a placenta-induced disease with resulting inflammation and coagulation involving the liver. Sinusoidal thrombi cause periportal hematoma, which can expand to result in subcapsular hematoma or hemoperitoneum. Imaging features in addition to hemorrhage that suggest this diagnosis are hepatomegaly, steatosis, and periportal edema.”
Bleeding Liver Masses: Imaging Features With Pathologic Correlation and Impact on Management
Thomas AJ et al.
AJR 2019; 213:1–9 - “Peliosis is a rare rare condition that occurs in association with a variety of conditions, including Bartonella infection in patients with HIV infection, chronic wasting diseases, solid organ transplant, and use of certain medications. Peliosis is usually asymptomatic and thus is often incidentally diagnosed. Peliosis consists of dilated hepatic sinuses that enlarge into blood-filled lacunes that may eventually rupture. CT images may show peliotic cavities in the liver that may contain variable amounts of hemorrhage. A characteristic enhancing central dot (target sign) and progressive centrifugal enhancement are seen at multiphase CT and MRI. Similar findings can be seen in other organs, most commonly the spleen.”
Bleeding Liver Masses: Imaging Features With Pathologic Correlation and Impact on Management
Thomas AJ et al.
AJR 2019; 213:1–9 - Patients with cirrhosis may also experience spontaneous hemorrhage even in the absence of HCC; regenerative nodules, likely in combination with coagulopathy, have been reported to hemorrhage spontaneously Because of the rarity of hemorrhage with these causes, they are not discussed in detail herein but may be considered in the appropriate clinical setting.”
Bleeding Liver Masses: Imaging Features With Pathologic Correlation and Impact on Management
Thomas AJ et al.
AJR 2019; 213:1–9 - “A broad spectrum of neoplastic and other pathologic conditions can result in hepatic hemorrhage. They have the potential for dev- astating consequences in cases of rupture, including hemorrhagic shock, abdominal compartment syndrome, and intraperitoneal tumor spillage. One can often narrow the differential diagnosis considerably by taking into account both the imaging features and aspects of the clinical history that may suggest a particular diagnosis.”
Bleeding Liver Masses: Imaging Features With Pathologic Correlation and Impact on Management
Thomas AJ et al.
AJR 2019; 213:1–9
- Hepatic Bleeding: Differential Dx
- Trauma
- Anticoagulation therapy
- Biopsy
- Hepatic adenoma
- Hepatoma
- Hemangioma
- Metastases (melanoma)
- Complication of chemotherapy - Hepatic Bleeding due to Tumors
- Hepatic adenoma
- Hepatoma
- Hemangioma
- Metastases (melanoma)
- Lymphoma
- Angiosarcoma