The Journal of Emergency Medicine, Vol. -, No. -, pp. 1–2, 2015 Copyright Ó 2015 Elsevier Inc. Printed in the USA. All rights reserved 0736-4679/$ - see front matter

http://dx.doi.org/10.1016/j.jemermed.2015.02.012

Visual Diagnosis in Emergency Medicine

HYPOVOLEMIC SHOCK CAUSED BY A RUPTURED HEMORRHAGIC HEPATIC CYST Sheng-Huei Wang, MD,* Chang-Hsien Liu, MD,† Yu-Pang Lin, MD,† and Wei-Kuo Chang, MD* *Department of Internal Medicine Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan, ROC and †Department of Radiology, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan, ROC Reprint Address: Wei-Kuo Chang, MD, Division of Gastroenterology, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan, No. 325, Section 2, Cheng-Kung Road, Neihu 114, Taipei, Taiwan.

sudden onset of tachycardia, hypotension, and increased abdominal pain developed. Physical examination revealed pale conjunctiva and shifting dullness of the abdomen. Hemoglobin levels decreased from 10.3 g/dL to 6.9 g/dL. Ultrasonography of the liver showed a hyperechoic mass with blood flow and free fluid around the liver (Figure 2). Diagnostic paracentesis disclosed bloody ascites and no malignant cells. A new CT scan demonstrated increased attenuation of the hepatic cyst and massive ascites (Figure 1B). The size of the cyst decreased from 7.9 cm to 6.8 cm, and the Hounsfield

CASE REPORT A 71-year-old man presented to our Emergency Department with dull abdominal pain in the right upper quadrant for 4 days. His medical history included liver cirrhosis, uremia, and a 3.8-cm simple hepatic cyst on computed tomography (CT) scan 4 years previously. Physical examination revealed right hypochondrial tenderness without muscle guarding. CT of the abdomen revealed mild ascites and a 7.9-cm cyst with a hyperdense component in segment 6 of the liver (Figure 1A). Twenty hours later,

Figure 1. Computed tomography (CT) images of hepatic cyst from intracystic hemorrhage to cyst rupture. (A) CT of the abdomen showed a 7.9-cm hepatic cyst with hyperdense component in segment 6 of the liver (arrow) and mild ascites (history of cirrhosis). (B) The CT scan performed after hypovolemic shock disclosed increased attenuation of the hepatic cyst and massive ascites (arrow) with increased Hounsfield units.

RECEIVED: 8 October 2014; FINAL SUBMISSION RECEIVED: 7 February 2015; ACCEPTED: 18 February 2015 1

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Figure 2. Ultrasonography showed one hyperechoic nodule mass (arrow) in segment 6 of liver with blood flow under Doppler.

unit level of ascites increased from 10 to 40. A ruptured hemorrhagic hepatic cyst was diagnosed. The patient received blood and clotting factors transfusion, but did not undergo surgical intervention due to multiple comorbidities. He was discharged 11 days later and his condition remained stable in the follow-up evaluation. DISCUSSION A ruptured hemorrhagic hepatic cyst is rare and occurs preferentially in patients with hepatorenal polycystic disease (1). The risk of cyst wall rupture is related to the intracystic pressure by secretion of the biliary epithelium, but not to the abdominal pressure (1). The particular risk factor in the present case was anticoagulant treatment during hemodialysis. Progressive abdominal pain in the right upper quadrant is the most common symptom (2). Surgical interventions, including unroofing, cyst enucleation, and hepatic resection, are indicated in patients with persistent symptoms and hemodynamic decompensation (2). A hemorrhagic hepatic cyst should be suspected when CT or ultrasonography shows intrinsic heterogeneity of

the cyst. However, it is a clinical challenge to differentiate hemorrhagic hepatic cysts from cystic liver tumors such as cystadenocarcinoma, even with modern radiologic imaging techniques. The diagnostic dilemma is that blood clots with liquefaction in hemorrhagic hepatic cysts mimic cystic liver tumors when the tumors are bleeding. Definite diagnosis of a hemorrhagic hepatic cyst depends on the thorough histopathologic survey of the whole hepatic cyst. One exception is when morphological changes in the cyst can be detected on serial radiologic examinations in a patient with previous diagnosis of liver cyst, as in this case (3). REFERENCES 1. Marion Y, Brevartt C, Plard L, Chiche L. Hemorrhagic liver cyst rupture: an unusual life-threatening complication of hepatic cyst and literature review. Ann Hepatol 2013;12:336–9. 2. Fong ZV, Wolf AM, Doria C, Berger AC, Rosato EL, Palazzo F. Hemorrhagic hepatic cyst: report of a case and review of the literature with emphasis on clinical approach and management. J Gastrointest Surg 2012;16:1782–9. 3. Kitajima Y, Okayama Y, Hirai M, et al. Intracystic hemorrhage of a simple liver cyst mimicking a biliary cystadenocarcinoma. J Gastroenterol 2003;38:190–3.

Hypovolemic Shock Caused by a Ruptured Hemorrhagic Hepatic Cyst.

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