A 32-year-old woman is brought to the emergency department an hour after developing acute-onset, right upper quadrant abdominal pain followed by syncope. The patient works at her family farm and felt well prior to the onset of these symptoms. She has no chronic medical conditions. She is sexually active and uses combined estrogen-progestin oral contraceptives. She does not use tobacco, alcohol, or illicit drugs. Temperature is 38.1 C (100.6 F), blood pressure is 80/50 mm Hg, pulse is 120/min, and respirations are 20/min. Oxygen saturation is 95% on room air. The patient appears anxious and pale. Examination shows abdominal distention, diffuse abdominal tenderness, and tender hepatomegaly. Bowel sounds are decreased. Extremities are cold, and capillary refill is delayed. Laboratory results are as follows: Abdominal ultrasound of the right upper quadrant shows a solid liver mass and free fluid in the abdomen. Which of the following is the most likely diagnosis?

Question

A 32-year-old woman is brought to the emergency department an hour after developing acute-onset, right upper quadrant abdominal pain followed by syncope.  The patient works at her family farm and felt well prior to the onset of these symptoms.  She has no chronic medical conditions.  She is sexually active and uses combined estrogen-progestin oral contraceptives.  She does not use tobacco, alcohol, or illicit drugs.  Temperature is 38.1 C (100.6 F), blood pressure is 80/50 mm Hg, pulse is 120/min, and respirations are 20/min.  Oxygen saturation is 95% on room air.  The patient appears anxious and pale.  Examination shows abdominal distention, diffuse abdominal tenderness, and tender hepatomegaly.  Bowel sounds are decreased.  Extremities are cold, and capillary refill is delayed.  Laboratory results are as follows:  Abdominal ultrasound of the right upper quadrant shows a solid liver mass and free fluid in the abdomen.  Which of the following is the most likely diagnosis?

Quizplus · Accepted Answer

11ec25c8_d83d_d3ba_bc81_5329d08cb0fb_MD0003_00 This patient's hypotension, tachycardia, syncope, poor capillary refill, cold extremities, and anemia indicate likely hemorrhagic shock. Given her sudden-onset, severe right upper quadrant pain, solid liver mass, and free abdominal fluid, the most likely underlying cause is a ruptured hepatic adenoma. Hepatic adenomas generally arise in young women who have been on prolonged estrogen-based oral contraception. Although considered benign and often discovered incidentally on imaging for other conditions, hepatic adenoma can cause life-threatening complications such as malignant transformation and rupture. Rupture should be suspected in those with sudden-onset, severe right upper quadrant pain who have signs of hemorrhagic shock; low-grade fever and mild leukocytosis also sometimes occur due to peritoneal irritation from blood in the abdominal cavity. Ultrasound generally reveals a single, solid liver lesion (usually in the right hepatic lobe) and free fluid (blood) in the abdomen. Urgent circulatory support and surgical intervention are required to prevent death. (Choice A) Focal nodular hyperplasia is a benign liver lesion seen most often in young women. It is not linked to oral contraception use and is usually asymptomatic; complications such as rupture or malignant transformation do not generally occur. (Choice B) Hepatic abscess is most common in the setting of bowel perforation or biliary infection. Although patients often have fever and progressive right upper quadrant pain, the presence of sudden right upper quadrant pain and hemorrhagic shock (eg, syncope, poor perfusion/capillary refill) would be atypical. In addition, ultrasound usually shows a lesion with internal debris or septation (not a solid mass). (Choice D) Hepatic hemangioma is the most common benign liver lesion. It is generally asymptomatic, but larger lesions can sometimes cause right upper quadrant pain. Spontaneous rupture of this vascular lesion is very rare; therefore, a solid liver lesion with surrounding free fluid is unlikely. (Choice E) Hepatocellular carcinoma usually occurs in older individuals with long-standing alcohol abuse or chronic viral hepatitis. Most cases present with progressive, subacute right upper quadrant abdominal pain or decompensated cirrhosis. This young patient with no history of chronic hepatitis or alcohol abuse is unlikely to have hepatocellular carcinoma. (Choice F) Hydatid cysts can occasionally rupture into the abdomen, leading to sudden-onset, right upper quadrant pain, fever, and leukocytosis. However, ultrasound would reveal a smooth, round cyst in the liver, not a solid mass. Educational objective: Young women on prolonged oral contraception are at greatest risk for hepatic adenoma. Although most lesions are benign and asymptomatic, life-threatening complications such as malignant transformation or rupture can occur. Rupture should be suspected in the setting of sudden-onset, severe right upper quadrant pain and signs of hemorrhagic shock.

A 32-Year-Old Woman Is Brought to the Emergency Department an Hour