ACUTE INTRAHEPATIC BLEEDING IN A MAN WITH FOCAL NODULAR HYPERPLASIA OF THE LIVER

History and clinical findings: A 45-year-old man had acute bouts of pa in in the right lower thorax with radiation to the mid-thorax and uppe r abdomen. For 3 years he was known to have coronary heart disease, fo r 4 years arterial hypertension and for 8 months, as an accidentally d iscovered finding, a liver cyst 2.5 cm in diameter, as well as an inho mogeneous focal lesion, demonstrable only by sonography, lying dorsall y and close to the diaphragm in the right lobe of the liver, 3.0 x 3.5 cm which was not detected by computed tomography or magnetic resonanc e imaging. Physical examination at admission detected epigastric pain on pressure but no other abnormalities. Investigations: Sonography sho wed the inhomogeneous hepatic lesion now to be 6.0 x 7.5 cm. Computed tomography demonstrated a space-occupying mass, 7.5 cm in diameter, do rsal to the hepatic cyst, partly hypo-, partly hyper-dense with margin al spotty enhancement after contrast-medium injection. Treatment and c ourse: As acute bleeding into the focal hepatic lesion was suspected, a laparotomy was performed and liver segments VII and VIII resected. O n inspection there was a sharply demarkated yellowish-white tumor with a central haemorrhagic softening. Histology revealed focal nodular hy perplasia (FNH) without signs of malignancy. Conclusion: In the case o f a known but not definitively diagnosed focal hepatic lesion, acute u pper abdominal pain can be a sign of acute bleeding into the lesion.