P2600 - Spontaneous Hepatic Rupture of Metastatic Adrenal Cortical Carcinoma Leading to Hemorrhagic Shock

Navina Mohan, MD¹, Jahnavi Udaikumar, MD², Ixel Cervera, MD¹, Tyler Fugere, MD¹, Tamta Chkhikvadze, MD³, Naveena Luke, MD⁴, Ceena Chandrabos, MD⁵, Saikiran Kilaru, MD^5
1NYU Langone Hospital-Brooklyn, Brooklyn, NY; ²NYU Grossman School of Medicine, Brooklyn, NY; ³SUNY Downstate Health Sciences University, Brooklyn, NY; ⁴Family Health Centers at NYU Langone, Brooklyn, NY; ⁵NYU Langone Health, New York, NY

Introduction: Liver metastases, though common, very rarely lead to spontaneous rupture and life-threatening intraperitoneal hemorrhage when compared to hepatocellular carcinoma (HCC). ACC is an aggressive and poorly understood tumor commonly metastasizing to the liver, lungs, or bone. This is a unique case of spontaneous hemoperitoneum from hyper-vascular ACC liver metastases.

Case Description/Methods: The patient is a 56-year-old female with a past medical history of functional ACC metastatic to the lungs and liver and prior recent pulmonary emboli (on apixaban), now presenting with worsening dyspnea and hypoxia. Chest imaging revealed no acute PEs, but worsening metastatic nodules, and presumed pneumonitis. She was transitioned to therapeutic enoxaparin. Later, she became febrile and hypotensive, requiring pressors. Her hemoglobin reduced from 14.9 to 10.6 over 10 hours. Her abdomen became distended and tympanic. Her liver enzymes steeply up-trended (aspartate aminotransferase (AST) 104 to 4522 and alanine transaminase (ALT) 93 to 2346). An abdominal computed tomography angiogram (CTA) revealed a new large hemoperitoneum with active contrast extravasation near a 7.2x6.7 cm segment 6 liver mass and multiple other large hyper-vascular liver metastases. Interventional radiology (IR) embolized the posterior division of the right hepatic artery and 2 accessory segment 6 branches. Post-op, she remained intubated with elevated airway pressures, persistent abdominal distension, and worsening pressor requirements, in spite of extensive blood transfusions. Due to concern for abdominal compartment syndrome, the patient underwent a decompressive laparotomy during which 3L of dark blood was evacuated, the peritoneum was irrigated, and hemostasis was confirmed. Simultaneously, pressor requirements and ventilator settings improved.

Discussion: Rupture and hemorrhage of liver metastases is extremely rare compared to HCC due to their fibrotic nature and less vascularity or liver capsule penetration. Metastasis-associated spontaneous hemoperitoneum has a poorer prognosis due to its complicated presentation and delays in diagnosis. Surgical resection of the metastasis may be an option once the patient has been stabilized and hemostasis has been achieved, but it is associated with high mortality. In summary, patients with liver metastases who develop hypotension of unclear etiology, unexplained fevers, or abdominal distension must be worked up for possible hepatic rupture.



Disclosures:


Navina Mohan, MD¹, Jahnavi Udaikumar, MD², Ixel Cervera, MD¹, Tyler Fugere, MD¹, Tamta Chkhikvadze, MD³, Naveena Luke, MD⁴, Ceena Chandrabos, MD⁵, Saikiran Kilaru, MD⁵. P2600 - Spontaneous Hepatic Rupture of Metastatic Adrenal Cortical Carcinoma Leading to Hemorrhagic Shock, ACG 2023 Annual Scientific Meeting Abstracts. Vancouver, BC, Canada: American College of Gastroenterology.