Haemoperitoneum from actively bleeding liver metastatic melanoma

Clinical History

Sudden onset of severe abdominal pain with marked tenderness in epigastrium and right hypochondrium, accompanied by hypotension and falling haematocrit in a patient with known liver and skeletal metastasation from previously resected cutaneous melanoma.
No history of recent trauma, chronic liver disease, coagulopathy or anticoagulant therapy.

Imaging Findings

Three months before, follow-up ultrasound and CT disclosed scattered hypoechoic liver metastases (up to 3 cm), some of them peripherally vascularised and subcapsular; spinal MRI detected multiple lumbar metastases. The oncologist prescribed supportive treatment only.
At Emergency Department admission, CT was immediately requested to investigate clinical suspicion of acute abdomen with impendent shock. On unenhanced images, comparison with previous studies detected marked liver enlargement and inhomogeneity, plus appearance of diffuse peritoneal effusion that measured hyperdense (45-50 HU) in the perihepatic area.
Contrast-enhanced acquisition confirmed markedly progressed liver involvement with innumerable confluent, variable-sized metastases. A dominant subcapsular metastasis showed fluid level consistent with intralesional haemorrhage in unenhanced images, and appearance of a strongly hyperattenuating focus during vascular phase acquisition, consistent with contrast extravasation indicating active bleeding.
Haemoperitoneum from bleeding, ruptured hepatic metastases was diagnosed. Surgical and interventional procedures were deemed contraindicated because of the patient’s poor general conditions, leading to exitus.

Discussion

Spontaneous, non-traumatic intraperitoneal haemorrhage is an uncommon, life-threatening occurrence, most usually secondary to ruptured hypervascular liver tumours, gynaecologic disorders or vascular lesions [1-3].
Compared to hepatocellular carcinoma or adenoma rupture, hemoperitoneum secondary to bleeding hepatic metastases is extremely rare, because the more fibrotic, hypovascular and less invasive pathological features of most metastases cause a limited incidence of capsular penetration and bleeding [2, 4, 5]. Sporadic cases from lung, pancreas, nasopharynx, stomach, kidney, breast, prostate tumours and choriocarcinoma have been reported, whereas lung, renal and melanoma rank as the most frequent primaries [6-8].
Hemoperitoneum represents a dramatic, usually fatal event in oncologic patients with liver metastatization. Clinical presentation may include unexplained blood loss, syncope, shock and acute abdomen sometimes mimicking visceral perforation [4-6, 9].
Because of its speed and widespread availability, CT is almost invariably used to diagnose hemoperitoneum from liver bleeding, appearing as high-density (usually in the range 30-45 HU) perihepatic, pelvic or diffuse effusion due to its high protein content; peritoneal blood may appear less dense when than 48 hours or in patients with reduced haematocrit levels. The sentinel clot represents the clotted, highest attenuation (45-70 HU) blood nearest to the source of bleeding. Acquisition in (at least) arterial-dominant and portal venous phases after intravenous contrast injection allows to identify, characterise and stage focal liver liver lesions. Features suggesting rupturing liver tumour include peripheral location, liver contour protrusion and discontinuity associated with surrounding haematoma. As observed in this case, contrast extravasation suggesting active bleeding is seen as serpiginous or amorphous intralesional areas isoattenuating with arterial or venous vessels [1, 3, 9, 10].
In conclusion, this rare entity should be suspected when faced with acute abdomen with shock in neoplastic patients, particularly with history of melanoma, renal or lung cancer. Basal and multiphasic contrast-enhanced CT allows identification of both hemoperitoneum and bleeding liver tumour, plus differentiation of other causes such as hepatocellular carcinoma and arterial aneurysm rupture [1, 3, 5, 10]. Treatment is usually palliative, although surgical haemostasis, transarterial chemoembolization or hepatic resection have been attempted in some patients [6-8].

Differential Diagnosis List

Final Diagnosis

Haemoperitoneum secondary to bleeding liver melanoma metastases

URL:	https://www.eurorad.org/case/9727
DOI:	10.1594/EURORAD/CASE.9727
ISSN:	1563-4086