Retrospective Cohort Study
Copyright ©The Author(s) 2017. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastroenterol. Jul 7, 2017; 23(25): 4579-4586
Published online Jul 7, 2017. doi: 10.3748/wjg.v23.i25.4579
Management and outcome of hepatocellular adenoma with massive bleeding at presentation
Anne J Klompenhouwer, Robert A de Man, Maarten GJ Thomeer, Jan NM Ijzermans
Anne J Klompenhouwer, Jan NM Ijzermans, Department of Surgery, Erasmus MC, 3000 CA Rotterdam, the Netherlands
Robert A de Man, Department of Gastroenterology and Hepatology, Erasmus MC, 3000 CA Rotterdam, the Netherlands
Maarten GJ Thomeer, Department of Radiology, Erasmus MC, 3000 CA Rotterdam, the Netherlands
Author contributions: Klompenhouwer AJ, de Man RA and Ijzermans JNM designed the research and analyzed the data; Klompenhouwer AJ and Thomeer MGJ performed the research; Klompenhouwer AJ, de Man RA, Thomeer MGJ and Ijzermans JNM wrote the article; all authors read and approved the final article.
Institutional review board statement: The research was approved by the local institutional review board (No. MEC-2016-338).
Informed consent statement: Informed consent was waived by the local institutional review board.
Conflict-of-interest statement: The authors have no conflicts of interest to declare.
Data sharing statement: Original data, images, and statistical code are available from the corresponding author at j.ijzermans@erasmusmc.nl.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Correspondence to: Jan NM Ijzermans, MD, PhD, Professor, Department of Surgery, Erasmus MC, 3000 CA Rotterdam, the Netherlands. j.ijzermans@erasmusmc.nl
Telephone: +31-10-7040704 Fax: +31-10-2250647
Received: January 10, 2017
Peer-review started: January 12, 2017
First decision: February 23, 2017
Revised: March 13, 2017
Accepted: April 12, 2017
Article in press: April 12, 2017
Published online: July 7, 2017
Processing time: 177 Days and 17.4 Hours
Abstract
AIM

To evaluate outcome of acute management and risk of rebleeding in patients with massive hemorrhage due to hepatocellular adenoma (HCA).

METHODS

This retrospective cohort study included all consecutive patients who presented to our hospital with massive hemorrhage (grade II or III) due to ruptured HCA and were admitted for observation and/or intervention between 1999-2016. The diagnosis of HCA was based on radiological findings from contrast-enhanced magnetic resonance imaging (MRI) or pathological findings from biopsy or resection of the HCA. Hemorrhage was diagnosed based on findings from computed tomography or MRI. Medical records were reviewed for demographic features, clinical presentation, tumor features, initial and subsequent management, short- and long-term complications and patient and lesion follow-up.

RESULTS

All patients were female (n = 23). Treatment in the acute phase consisted of embolization (n = 9, 39.1%), conservative therapy (n = 13, 56.5%), and other intervention (n = 1, 4.3%). Median hemoglobin level decreased significantly more on days 0-3 in the intervention group than in the patients initially treated conservatively (0.9 mmol/L vs 2.4 mmol/L respectively, P = 0.006). In total, 4 patients suffered severe short-term complications, which included hypovolemic shock, acute liver failure and abscess formation. After a median follow-up of 36 mo, tumor regression in non-surgically treated patients occurred with a median reduction of 76 mm down to 25 mm. Four patients underwent secondary (elective) treatment (i.e., tumor resection) to address HCA size of > 5 cm and/or desire for future pregnancy. One case of rebleeding was documented (4.3%). None of the patients experienced long-term complication (mean follow-up time: 36 mo).

CONCLUSION

With a 4.3% risk of rebleeding, secondary (elective) treatment of HCA after massive hemorrhage may only be considered in patients with persistent HCA > 5 cm.

Keywords: Hepatocellular adenoma; Management; Bleeding; Outcome; Hemorrhage

Core tip: As massive bleeding due to ruptured hepatocellular adenoma (HCA) is rare, we present a unique series of 23 consecutive patients. To our knowledge, this is the first study to assess the outcome and sequelae of the massive bleeding complication, including risk of rebleeding and need for elective tumor resection. In our series, risk of rebleeding was 4.3% and most HCAs regressed spontaneously. No long-term complications were documented. These cases suggest that a wait-and-watch policy may be legitimate and secondary (elective) treatment may only be considered for persistent HCA > 5 cm after follow-up and/or for patients with desire for future pregnancy.