RUPTURE AND HEMORRHAGE OF HEPATIC FOCAL NODULAR HYPERPLASIA

Although adenoma and focal nodular hyperplasia (FNH) are both benign l iver lesions, adenomas are associated with a risk of rupture and malig nant degeneration. This had led to the general recommendation of resec tion of adenomas. However, FNH rarely ruptures or becomes malignant, a nd a nonoperative approach has been adopted by most hepatobiliary cent ers when the diagnosis of FNH can be made with reasonable certainty. T here are only two previous reports of rupture of FNH in the English li terature; we present a third case of FNH with spontaneous rupture and hemorrhage. An 18-year-old healthy Caucasian woman presented with sudd en onset of severe RUQ pain. She had never been pregnant, nor used ora l contraceptive agents, and had not sustained major trauma. Her abdomi nal exam revealed RUQ tenderness on palpation. Hepatic biochemical tes ts, CBC, and coagulation tests were normal. Her hematocrit of 44% fell to 31% over 48 hours. CT scan revealed right anterior lobe and left m edial segment hypodense liver lesions (4-5 cm) as well as hemoperitone um and angiography revealed hypervascular lesions. At laparotomy, two tan fibrous subcapsular masses were excised. Pathology showed a centra l stellate scar in both lesions with several nodules surrounding the c entral scar on microscopic section, characteristic of FNH. There was e vidence of hemorrhage in one lesion. Significant symptoms are an indic ation for resection of FNH lesions. However, most patients with FNH ar e asymptomatic and have a normal physical exam. The natural history of these lesions is enigmatic, and the indications for surgery are still evolving. This report emphasizes that a small risk of rupture clearly exists. Although hemorrhage is rare, this possibility and its potenti al consequences need to be considered in treatment decisions.