Isin Y. Comba, MD1, Richard Henriquez, MD2, Sundeep Kumar, MD1, Ruthvik Srinivasamurthy, MD1, Maria Wallis-Crespo, MD3, Olga Karasik, MD1, Lakhinder Bhatia, MD3
1University of Central Florida College of Medicine, Kissimmee, FL; 2University of Central Florida College of Medicine, Orlando, FL; 3Osceola Regional Medical Center, Kissimmee, FL
Introduction: Hepatocellular adenoma (HCA) is a benign tumor of the liver and almost always located intracapsular. Bleeding (25%), and malignant transformation (5%) can complicate the disease course if left untreated. Herein, we present a case of extracapsular HCA of ectopic liver in the omentum complicated with intraperitoneal hemorrhage.
Case Description/Methods: A 43-year-old lady with no past medical history presented to emergency department with two-day history of left shoulder pain and epigastric discomfort. Her only medication was an oral contraceptive pill (OCP). On physical exam, the patient had persistent sinus tachycardia, and epigastric tenderness. Initial labs were unremarkable except for mildly elevated AST at 58 IU/L (10-37). CT of the abdomen with IV contrast showed a heterogeneously enhancing mass likely arising from the anterior wall of the stomach. T2-weighted MRI abdomen demonstrated a hypoenhancing mass measuring 4 x 7 x 8 cm with adjacent hemorrhage (Image 1). Exploratory laparotomy revealed an infarcted, hemorrhagic mass between the fundus of the stomach, spleen, and diaphragm with a large amount of clots and free blood occupying the greater curvature. The mass was separated from surrounding viscera however, slightly attached to the diaphragm. The mass was removed with the completely resolved tachycardia and epigastric pain postoperatively. Initially, the lesion was thought to be an accessory spleen based on location and gross examination. Microscopically, an infarcted, hemorrhagic mass composed of cords of degenerated epithelioid cells with vacuolated cytoplasm was surrounded by reactive fibro- and myofibroblastic tissue. Epithelioid cells were diffusely stained for HerPar-1 (hepatocyte origin), and CK AE1/AE3 (image 2). These findings were consistent with HCA.
Discussion: HCA is an overlooked diagnosis and can result in serious complications if unrecognized. Among the well-known risk factors of HCA are OCPs or anabolic steroids, pregnancy, and steatohepatitis. The prevalence of these lesions has been rising parallel to increasing use of OCP and abdominal imaging. In females, lesions < 5cm with no associated symptoms or complications can be managed conservatively by terminating OCP use, and surveillance. Our patient presented with acute left shoulder pain which was likely due to phrenic nerve irritation by bleeding (Kehr’s sign). To best of our knowledge, there are only three cases of extracapsular HCA reported in the English literature.
Citation: Isin Y. Comba, MD; Richard Henriquez, MD; Sundeep Kumar, MD; Ruthvik Srinivasamurthy, MD; Maria Wallis-Crespo, MD; Olga Karasik, MD; Lakhinder Bhatia, MD. P2545 - EXTRACAPSULAR HEPATOCELLULAR ADENOMA: A DIAGNOSTIC DILEMMA. Program No. P2545. ACG 2019 Annual Scientific Meeting Abstracts. San Antonio, Texas: American College of Gastroenterology.