LAUSR

A 51-year-old male presented to a rural hospital with severe abdominal pain and tachycardia. Haemoglobin (Hb) was 58 g/L and CT angiogram demonstrated enlargement of what was thought to be haemangioma of the liver from 11 to 14 cm with no active contrast extravasation. He was resuscitated with 4 units of packed red blood cells (PRBCs) and crystalloids and administered platelets, tranexamic acid and prothrombin complex concentrate and then transferred to our institution. This lesion was identified incidentally 3 months prior to presentation on a trauma CT scan. Discussion at our Hepato-pancreato-biliary MDM felt that this represented a haemangioma (Fig. 1). Past history include multiple myeloma in remission for 7 years. On arrival to our hospital the patient had a distended, tender abdomen with a large mass in the right upper quadrant. Hb was 77 g/L and coagulation studies demonstrated disseminated intravascular coagulation. Repeat CT angiography was performed demonstrating a right liver lesion measuring 16 x 21 x 22 cm with associated haemoperitoneum and multiple lung nodules, not seen on the previous scans (Fig. 2). No contrast extravasation was seen on the arterial or delayed phase. He was initially managed conservatively with replacement of blood products and correction of coagulopathy as his haemodynamics improved, and there was no particular vessel to target angiographically. Furthermore, his estimated functional residual liver volume was only 12%. On D3 of his admission, the patient became unresponsive and hemodynamically unstable with an associated increase in abdominal distension and drop in haemoglobin from 98 to 68 g/L. Massive transfusion protocol was commenced and he was taken for urgent angioembolisation of the right hepatic artery. The immediate period following embolisation saw cardiorespiratory deterioration and the development of abdominal compartment syndrome. Due to his young age and excellent pre-morbid functional status, the decision was made to proceed to surgery after discussion with a liver transplant unit.