Management of Ruptured Hepatic Adenoma

Background: Why Adenomas Rupture

Phase 1: Acute Hemorrhage Control

Hemodynamically Stable Patient

• TAE can rapidly arrest hemorrhage with high technical success
• It allows the patient to be resuscitated and stabilized before definitive surgery
• After successful TAE and stabilization, the patient is referred for elective surgical resection (usually 4-8 weeks later)
• In rare cases where follow-up MRI shows no residual lesion post-embolization, resection may be deferred

"Transarterial embolization may be used before surgery to reduce the size of the lesion and is the treatment of choice for bleeding control in cases of acute rupture. After the bleeding is controlled, the patient is referred for surgical resection..." - Current Surgical Therapy 14e

Hemodynamically Unstable Patient / TAE Not Available

1. Abdominal packing (damage control) - perihepatic packs to tamponade bleeding
2. Pringle maneuver (hepatoduodenal ligament inflow occlusion) for intraoperative bleeding control
3. Hepatic artery ligation as a last resort if packing fails

• Pack and close temporarily
• Transfer to ICU for aggressive resuscitation and correction of coagulopathy
• Return to OR for definitive resection once physiologically optimized

"For patients who present with acute hemorrhage from a ruptured adenoma for which embolization fails or is not an option, emergent laparotomy is indicated. Liver packing and inflow control with Pringle's maneuver are used for bleeding control. Resection may be performed at the same operation, but patients with acidosis, coagulopathy, or hypothermia may require resuscitation before the definitive operation." - Current Surgical Therapy 14e

Phase 2: Definitive Surgical Resection

• Prevent recurrent hemorrhage
• Exclude malignant transformation (especially beta-catenin subtype)
• Provide histologic diagnosis

Surgical Options

Management Algorithm (Fischer's Mastery of Surgery)

Special Scenario: Ruptured Adenoma in Pregnancy

• Rupture during pregnancy carries ~60% maternal and fetal mortality, even with operative intervention
• Presentation: right upper quadrant pain, right shoulder pain (diaphragmatic irritation), rapid progression to shock
• Immediate laparotomy is the standard of care: cesarean delivery + control of hemorrhage + adenoma resection if feasible
• Angioembolization can be considered if the patient is relatively stable or postpartum
• After recovery, elective resection during the second trimester minimizes operative risk while protecting the remainder of the pregnancy

"The major risk of a hepatic adenoma during pregnancy is spontaneous rupture, which carries a mortality rate of approximately 60% for mother and fetus, even with operative intervention... Immediate laparotomy is performed with cesarean birth, control of hemorrhage, and resection of the adenoma, if possible." - Sabiston Textbook of Surgery

Summary: Management Steps

RUPTURED HEPATIC ADENOMA
         |
    Hemodynamically?
   /               \
STABLE           UNSTABLE
   |                 |
  TAE            Laparotomy
(1st line)     + Packing/Pringle
   |                 |
Resuscitate    DCS if lethal triad
   |                 |
   +-----> Elective Resection (4-8 weeks) <----+

• Cessation of oral contraceptives / anabolic steroids
• Avoid future OCP use and counsel on pregnancy risks
• Surveillance imaging to confirm no recurrence

Sources

• Current Surgical Therapy, 14e - Management section on hepatic adenoma
• Fischer's Mastery of Surgery, 8e - Chapter 160, Figure 160.7
• Sabiston Textbook of Surgery - Liver Disorders / Liver Disease in Pregnancy
• Mulholland and Greenfield's Surgery, 7e - Hepatic Adenoma
• Yamada's Textbook of Gastroenterology, 7e - Benign hepatic lesions
• PMID 37490115 (Robotic hepatectomy for hemorrhagic adenoma, Am Surg 2023)