A 34-year-old woman taking combined oral contraceptives for 8 years presents with sudden severe right upper quadrant pain and hypotension. CT shows a 7 cm heterogeneous right lobe liver mass with a large subcapsular haematoma and free intraperitoneal blood. After initial resuscitation, definitive management is:

• A Transarterial embolization alone, with lifelong follow-up imaging
• B Urgent surgical exploration with resection of the lesion where feasible ✓
• C Discontinuation of oral contraceptives and repeat imaging in 6 months
• D Percutaneous biopsy of the lesion to establish histology

Explanation

This is a ruptured hepatic adenoma causing life-threatening haemoperitoneum. After resuscitation and stabilisation, bleeding lesions require operative intervention with resection of the adenoma when technically possible. Transarterial embolisation is a temporising option for the unstable patient or for tumours unsuitable for resection, not the endpoint here. Discontinuing oestrogens with observation applies only to small, unruptured adenomas. Percutaneous biopsy is contraindicated because these hypervascular lesions are prone to catastrophic haemorrhage and the clinical picture is already diagnostic.

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

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