A 28-year-old woman on combined oral contraceptives presents with sudden severe right upper quadrant pain and hypotension. CT shows a 7 cm well-circumscribed right lobe hepatic mass with active contrast extravasation and free intraperitoneal blood. After initial resuscitation, the definitive management is:

• A Discontinue oral contraceptives and observe with serial imaging
• B Immediate open hepatic resection in all cases
• C Percutaneous drainage and antibiotics
• D Urgent transarterial embolisation followed by elective resection once stable ✓

Explanation

Ruptured hepatic adenoma with haemoperitoneum is first managed with resuscitation and transarterial embolisation to control bleeding; resection is then undertaken electively in most patients because of ongoing rupture risk, though observation may suffice if the tumour completely infarcts. Immediate laparotomy with resection in an unstable coagulopathic liver is avoided where embolisation is available. Observation alone is inadequate after rupture.

Reference: Blumgart's Surgery of the Liver, Biliary Tract and Pancreas, 6th ed.

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