G a s t r o i n t e s t i n a l I m a g i n g • R ev i ew

Thomas et al.
Bleeding Liver Masses

Gastrointestinal Imaging
Review

Bleeding Liver Masses: Imaging

FOCUS ON:

Features With Pathologic Correlation

and Impact on Management
Aaron J. Thomas1 OBJECTIVE. The purposes of this article are to discuss a variety of liver masses that can
Christine O. Menias 2 present with hemorrhage, including their characteristic imaging features, and to propose a di-
Perry J. Pickhardt 3 agnostic approach.
Akram M. Shaaban 4 CONCLUSION. A broad spectrum of pathologic conditions can present as spontaneous
Ayman H. Gaballah5 hemorrhage within or surrounding the liver and may present acutely or as a chronic or inci-
dental finding. Imaging characteristics and clinical history can often narrow the differential
Sireesha Yedururi 6
diagnosis and guide management.
Khaled M. Elsayes 6
epatic hemorrhage occurs in a presses the liver [5]. Subcapsular extension

H
Thomas AJ, Menias CO, Pickhardt PJ, et al.
wide variety of pathologic condi- is more likely with peripherally located le-
American Journal of Roentgenology

tions [1]. If present, a causative sions [6, 7]. When it is no longer contained
lesion can often be identified on by the capsule, the hemorrhage can rupture
Keywords: bleeding, imaging, liver, management, the basis of characteristic imaging findings into the peritoneal space (Fig. 2). This can
masses, pathologic correlation and clinical history, but the diagnosis may be have devastating consequences, such as hem-
doi.org/10.2214/AJR.19.21240
delayed because of distortion or obscuration orrhagic shock and abdominal compartment
of the underlying lesion in the presence of syndrome [8].
Received January 31, 2019; accepted without revision acute hemorrhage [2]. A broad spectrum of Although patients with hepatic hemor-
February 7, 2019. hepatic neoplasms and metastatic lesions in rhage often present with nonspecific symp-
the liver can cause hemorrhage [3]. Nonneo- toms, if they have acute abdominal pain, CT
Based on a presentation at the Radiological Society of
North America 2017 annual meeting, Chicago, IL. plastic causes of hepatic hemorrhage should is the modality of choice because of its wide-
also be considered, depending on the clinical spread availability, rapid acquisition, and an-
1
Department of Radiology, Baylor College of Medicine, scenario and imaging findings, because they atomic detail [9]. An acute bleed typically
Houston, TX.  can be difficult to differentiate. manifests as a hyperattenuating collection
2 Clinical presentation is determined by [10]. Blood often first clots near its source,
Department of Radiology, Mayo Clinic Arizona,
Scottsdale, AZ.  the acuity of the bleed, the volume of blood and a collection of clotted hyperattenuating
loss, and the location of the inciting lesion. blood near the liver may therefore provide a
3
Department of Radiology, University of Wisconsin Hepatic hemorrhage exists along a spec- clue to a hepatic source of hemoperitoneum.
School of Medicine and Public Health, Madison, WI.  trum, increasing in severity from clinically Similarly, a hyperattenuating focus within a
4
Department of Radiology, University of Utah, Salt Lake
insignificant bleeds to catastrophic abdom- lesion can indicate recently clotted blood at
City, UT.  inal hemorrhage. In the mildest form, tiny the origin of bleeding (sentinel clot sign) [2].
amounts of bleeding contained within a tu- Another clue to hepatic origin is focal dis-
mor can cause recurrent hemorrhage, which continuity of the hepatic contour at the site
5
Department of Diagnostic Radiology, University of
Missouri–Columbia, Columbia, MO. 
can be asymptomatic and often only detected of rupture [11]. Arterial phase imaging may
6
Department of Radiology, The University of Texas M D incidentally at MRI [4] (Fig. 1). reveal contrast extravasation, indicating ac-
Anderson Cancer Center, 1400 Pressler St, Houston, TX As the volume of hemorrhage increases, tive bleeding that may require urgent endo-
77030. Address correspondence to K. M. Elsayes a contained, intraparenchymal hematoma vascular therapy [12]. An ancillary sign of
(kmelsayes@mdanderson.org).  forms, which can exert local mass effect and severe bleeding is flattening of the inferior
Supplemental Data
contain a substantial volume of blood. Pa- vena cava, which can reflect hypovolemia or
Available online at www.ajronline.org. tients often present with nonspecific clini- shock. In addition, periportal areas of low at-
cal symptoms, such as pain, vomiting, and tenuation may result from aggressive fluid re-
AJR 2019; 213:1–9 malaise [1]. The hematoma can rupture into suscitation [13].
0361–803X/19/2131–1
the subcapsular space of the liver, where it is Hemorrhage is frequently seen on MR
contained between the liver and its capsule, images, although often in less acute cases.
© American Roentgen Ray Society resulting in an elliptic collection that com- Within the first 1–3 days of bleeding, blood

AJR:213, July 2019 1

 Thomas et al.

Fig. 1—74-year-old man with history of cirrhosis
related to hepatitis C. Axial unenhanced T1-weighted
MR image shows areas of heterogeneous intrinsic
T1 hyperintensity (arrow) compatible with internal
hemorrhage.
may appear as a T1-hypointense, T2-hypoin-
tense collection. After 3–5 days, intrinsic
T1-weighted signal intensity increases while
T2 signal intensity remains low [14]. Chron-
ic hemorrhage may leave behind deposits of
hemosiderin, which has low signal intensity
in all sequences and is often seen as a T2-hy-
American Journal of Roentgenology
tors include alcohol abuse, nonalcoholic fatty
liver disease, hemochromatosis, dietary ex-
posure to aflatoxins, and α1-antitrypsin defi-
ciency [17]. The annual incidence of HCC in
patients with cirrhosis is estimated at 2–8%,
risk depending on the severity of the cirrho-
sis, underlying cause (viral hepatitis being
the greatest risk), male sex, and coinfection
with HIV [18].
Although the prognosis of metastatic dis-
ease is poor, patients who are candidates for
curative transplant or resection may have a
5-year survival rate as high as 60–70% [19].
Screening is therefore commonly used, often
with a combination of serum α-fetoprotein
measurement and abdominal ultrasound ev-
ery 6 months for patients at high risk, in ac-
cordance with consensus guidelines [20, 21].
Screening with an abbreviated MRI study
has shown promise in increasing the sensi-
tivity and specificity of screening regimens
in several studies but has not yet been widely
adopted [22, 23]. Currently, multiphase CT
and MRI are the examinations of choice for
further evaluation of hepatic lesions in pa-
Internal hemorrhage is another frequently
noted feature of HCC at both histologic anal-
ysis and imaging [27–29] (Fig. 1). Areas of
internal hemorrhage are also common in pa-
tients who have undergone transarterial che-
moembolization [30] or chemotherapy, which
can result in hemorrhagic necrosis [31].
A frequent complication of these tumors is
rupture with hemorrhage into the subcapsu-
lar or peritoneal space. Estimated to occur in
3–15% of cases, this complication is a cause
of considerable morbidity and mortality (Fig.
3). Although an underlying lesion may fre-
quently be obscured or incompletely evalu-
ated in patients with an acute bleed, a high
index of suspicion should be maintained in
the care of patients with cirrhosis and hepatic
bleeding [32].
The cause of hemorrhage in HCCs is like-
ly multifactorial and is not completely under-
stood. Rupture may be facilitated by tumor
angiogenesis, which increases as it mutates
from a cirrhotic nodule to a dysplastic nod-
ule to HCC. This leads to an increasing pro-
portion of its vascular supply being derived

pointense rim in patients with chronic hem-
orrhage [15].
Malignant Liver Lesions
Hepatocellular Carcinoma
Hepatocellular carcinoma (HCC) is the
fifth most common malignancy in the world
among men and the seventh most com-
mon among women. It is the second lead-
ing cause of cancer-related mortality [16].
It is seen overwhelmingly in patients with
cirrhosis, most often as a sequela of hepati-
tis B or hepatitis C. Other predisposing fac-
tients at high risk. Characteristic findings
at multiphase contrast-enhanced CT and
MRI include enhancement in the late arte-
rial phase, washout in the portal venous and
delayed phases, and an enhancing capsule.
Ancillary MRI features include T2 hyperin-
tensity, restricted diffusion, and intralesional
fat [24]. Diagnosis may be difficult for small
lesions smaller than 1.5 cm, which are less
likely to have typical imaging features [25].
Tumors can be single, multifocal, or infiltra-
tive and frequently invade the portal venous
or hepatic venous system [26].
from new, unpaired hepatic arteries with di-
minishing contributions from the portal ve-
nous system [33]. Microinjuries and elastin
deposition in these small arteries may pre-
dispose to hemorrhage [34]. Other possible
mechanisms include hepatic venous occlu-
sion resulting in vascular congestion in the
surrounding area and preexisting portal hy-
pertension [35]. Patients with HCC are often
at increased baseline risk of bleeding due to
underlying cirrhosis-associated coagulop-
athy [1, 36]. Although they are common-
ly spontaneous, hemorrhagic complications

A B C
Fig. 2—26-year-old woman with spindle cell carcinoma metastasis from right kidney.
A, Axial contrast-enhanced CT shows enhancing peripheral liver mass (arrow) with large surrounding subcapsular hematoma.
B, Axial contrast-enhanced CT slice superior in relation to A shows active contrast extravasation (arrow).
C, Axial contrast-enhanced CT image shows extracapsular extension with hemoperitoneum (asterisk) extending to pelvis.

2 AJR:213, July 2019

 Bleeding Liver Masses

pervascular liver metastases, including neu-

Fig. 3—58-year-old man with history of cirrhosis
and hepatocellular carcinoma. Axial contrast-
enhanced CT image shows dominant peripheral mass
(arrow) with adjacent subcapsular hematoma and
hemoperitoneum (asterisk).
may also be precipitated by minor trauma or
transarterial chemoembolization [37, 38].
Key features that predispose a particular
tumor to rupture include its location within
the liver and its size. The highest-risk tumors
American Journal of Roentgenology
roendocrine tumors, renal cell carcinoma,
melanoma, choriocarcinoma, and sarcoma,
which may increase the risk of bleeding.
These are best evaluated in the arterial phase
of multiphase contrast-enhanced CT or MRI.
Less vascular lesions are often best seen in
the portal venous phase [45].
A broad spectrum of both hypervascular
and hypovascular tumors have been reported
to cause hepatic hemorrhage, but the relative
frequencies and risk factors for a specific le-
sion have not been established [3]. Metastatic
disease to the liver, although most commonly
presenting as multiple discrete lesions (Figs. 4
and 5), can have a diverse array of imaging ap- Fig. 4—27-year-old man with metastatic testicular
pearances, ranging from a solitary tumor to ex- nonseminomatous germ cell tumor. Axial contrast-
enhanced CT image shows numerous masses
tensive infiltrative disease. Metastatic lesions within both hepatic lobes, some of which display
can have a complex appearance due to internal internal hyperattenuating material, compatible with
hemorrhage, necrosis, or calcification. The di- subacute internal hemorrhage (arrows). Subcapsular
agnosis may also be suggested by the presence hematoma is also present (asterisk).
of an extrahepatic primary tumor [46, 47].
Hepatic Angiosarcoma
Hepatic angiosarcoma, although very

are large and within the periphery of the liv-
er, either abutting or protruding beyond the
capsule. The minimal thickness of peritumor
liver parenchyma and the degree of capsular
protrusion both have been associated with
increased risk of rupture [7, 39]. Other risk
factors that have been described include por-
tal venous thrombus, perihepatic invasion,
and a history of systemic hypertension [11,
40, 41]. It is important to remember that af-
ter resolution of the acute event, intraperito-
neal rupture of HCC can result in peritoneal
spillage of tumor. Follow-up imaging should
include a careful evaluation for the develop-
ment of peritoneal implants [42].
Hepatic Metastases
Metastases are the most common malig-
nant tumors in the liver. The liver is the most
common solid organ site of metastases. As
many as 50% of patients with a primary ma-
lignancy eventually have hepatic metastatic
disease [43]. Common primary tumors me-
tastasizing to the liver include adenocarcino-
ma from colorectal, breast, gastric, pancreat-
ic, and lung primaries [44].
Metastatic lesions can be grouped by their
relative vascular supply. That adenocarcino-
ma metastases are hypovascular compared
with primary liver tumors likely explains
their lower overall propensity to hemorrhage
compared with primary hepatic tumors [3].
However, several primary tumors cause hy-
rare, is the third most common primary he-
patic malignancy [48]. It has been associated
with a variety of environmental exposures,
most notably thorium dioxide (Thorotrast,
Testagar), arsenic, and polyvinyl chloride
[49, 50]. It is most commonly seen in men
in the sixth and seventh decades of life [51].
It is highly aggressive and often metastatic
at diagnosis; common sites include nearby
structures, such as the spleen, stomach, and
peritoneum, and distant sites, such as lungs,
bone, and brain [52].
As an endothelial tumor, angiosarcoma
is composed of abundant anastomosing vas-
cular channels with regions of necrosis and
blood-filled cysts [48]. At imaging it can
display one of several patterns, including a
dominant mass, multiple nodules, or diffuse
infiltrative tumor. Angiosarcoma is general-
ly hypervascular and exhibits heterogeneous
enhancement, potentially mimicking cavern-
ous hemangioma [53] (Fig. 6).
Rupture is a devastating complication of
hepatic angiosarcoma. In addition to the dan-
gers of the acute hemorrhage, spillage can
cause peritoneal angiosarcomatosis and sub-
sequent recurrent hemoperitoneum, which
have a dismal prognosis [54, 55].
Benign Liver Lesions
A number of benign neoplasms and non-
neoplastic entities can cause hepatic hemor-
rhage and have the appearance of a hemor-
Fig. 5—62-year-old man with metastatic gastric
gastrointestinal stromal tumor. Axial unenhanced CT
image shows multiple hepatic masses with internal
hemorrhagic density. Peripheral lesion (arrow) in
right lobe has internal hyperattenuation compatible
with hemorrhage. Small subcapsular hematoma
(asterisk) also is evident.
rhagic mass. We discuss several of the more
common lesions.
Hepatic Adenoma
Hepatic adenoma is a primary hepatic tumor
that gained recognition with the advent of oral
contraceptives. As hormonal concentrations in
these drugs have decreased, so has their associ-
ation with adenomas, and other risk factors for
adenomas have become increasingly important,
including obesity and metabolic syndrome [56–
58]. Additional risk factors for the development
of these tumors include anabolic steroids, gly-
cogen storage disease, and pregnancy [59].
Hepatic adenomas have been classified into
four subtypes based on molecular and patho-

AJR:213, July 2019 3

 Thomas et al.

Heterogeneous lipid may be seen in a minor-

ity of cases, but these do not exhibit the dif-
fuse steatosis seen in the HNF-1α–mutated
subtype [65]. Typically the inflammatory sub-
type is more intensely enhancing in the arte-
rial phase than are other subtypes and persists
throughout the portal venous and delayed
phases [63]. This hypervascularity is due to
the presence of dilated sinusoids fed by pe-
ripheral hepatic arterial vessels. This arterial
filling of sinusoids in combination with poor
connective tissue support is likely what pre-
disposes these tumors to hemorrhage [62].
Resection of adenomas is generally con-
sidered once lesions reach a diameter great-
er than 5 cm, because the likelihood of rup-
ture increases with lesion size (Figs. 7 and 8).
For patients who are not eligible for surgery,
A B other options include embolization or percu-
taneous ablation, although this practice may
evolve with advances in adenoma subtyping,
potentially allowing more conservative man-
agement of lower-risk lesions [66, 67].
American Journal of Roentgenology

Cavernous Hemangioma
Cavernous hemangioma is the most com-
mon benign hepatic lesion. It has a female
predominance of 5:1 and is often an inci-
dental finding with prevalence estimated at
1–20% in the general population [68]. Histo-
logically cavernous hemangioma consists of
blood-filled cavities with endothelial lining
and hepatic arterial supply [69]. The classic
appearance of a typical hemangioma is dis-
continuous nodular enhancement with cen-
tripetal filling on multiphase images. There
C D are, however, many atypical varieties of
hemangioma, including giant hemangioma,
Fig. 6—52-year-old man with ruptured hepatic angiosarcoma.
A, Axial unenhanced CT image shows ill-defined hypoattenuating lesion in right hepatic lobe with hyperdense
flash-filling capillary hemangioma, calci-
subcapsular hematoma (arrow). fied hemangioma, and hyalinized sclerosing
B, Axial contrast-enhanced CT image shows heterogeneous enhancement within lesion. hemangioma, which may be more difficult to
C, Angiogram obtained after CT shows hypervascular tumor supplied by hepatic artery. definitively diagnose with imaging [70].
D, Delayed image from same angiogram as C shows characteristic persistent puddling of contrast material
within tumor. Although rupture of hemangiomas with a
broad range of diameters, including lesions
logic subtypes, which also have key differenc- sity for hemorrhage, approximately 20–25% as small as 1 cm, has been reported, the risk
es in their imaging features, risk factors, and displaying intratumoral hemorrhage. Other appears to be strongly correlated to the size
complications [60]. Although most common- subtypes, including hepatocyte nuclear factor of the tumor. In a review [71] of reported
ly solitary tumors, in patients with adenoma- 1α (HNF-1α)−mutated adenomas, β-catenin– cases, the mean size of ruptured lesions was
tosis, adenomas are multiple, defined as more mutated adenomas, and unclassified subtype, 11.2 cm. The term giant hemangioma has
than 10. This condition has an unknown cause are thought to carry lower risk of hemor- been variably defined [70]. Most authors use
but can occur with or without oral contracep- rhage and rupture. Inflammatory adenomas a cutoff of 4 cm in diameter [71–73], but oth-
tive use and is potentially related to underly- have an approximately 10% chance of ma- ers have used values of 5 cm [74] or 6 cm
ing hepatic steatosis [61, 62]. lignant transformation, which is less than in [75]. Giant hemangiomas are generally well
Characteristic imaging findings of adeno- β-catenin–mutated adenomas but more than defined and have round or lobular margins.
ma include arterial enhancement with inter- in HNF-1α–mutated tumors [63]. Compared with their smaller counterparts,
nal T1 hyperintensity due to internal fat or A finding that suggests the inflammatory giant hemangiomas often have a more com-
hemorrhage [62]. The inflammatory subtype subtype is a peripheral T2-hyperintense band plex imaging appearance that includes inter-
is most common and has the greatest propen- on MR images, known as the atoll sign [64]. nal hemorrhage (Fig. 9) and areas of central

4 AJR:213, July 2019


necrosis, scarring, or calcification [70, 74,
75]. Another potential complication of these
large lesions is Kasabach-Merritt syndrome,
a consumptive coagulopathy that, although
more common in infants, can develop in
adults. It has a mortality rate of 10–37% [76].
Hepatic Cyst
Hepatic cysts are an extremely common
incidental finding, estimated to be present in
2.5–18% of patients [77]. They become more
common with advancing age, affect women
slightly more commonly than men, and are
usually solitary [78]. Although these cysts
are generally incidental findings, patients oc-
casionally present with pain or distention if
hemorrhage is present within the cyst [79].
Fig. 7—36-year-old
woman with prior
diagnosis of hepatic
adenomatosis. Axial
contrast-enhanced
CT image shows large
subhepatic hematoma
(asterisk) with foci of
enhancing tumor.
American Journal of Roentgenology
Fig. 8—51-year-old man with ruptured hepatic adenoma.
A, Axial contrast-enhanced CT image shows ruptured mass (arrow) in left hepatic lobe. Subcapsular hematoma and perisplenic hemoperitoneum (asterisk) are also
evident.
B, Photograph of gross specimen after hepatic lobectomy shows hemorrhagic tumor confirmed to be inflammatory subtype hepatic adenoma.
AJR:213, July 2019 5
Bleeding Liver Masses
The cyst loses its simple appearance and
may exhibit heterogeneous hyperattenuation
at CT [80] (Fig. 10). A hemorrhagic cyst can
be difficult to differentiate from a cystic neo-
plasm, such as a mucinous cystic neoplasm.
A mucinous cystic neoplasm may also have
septations and internal hemorrhage, and sus-
picion of complicating malignancy should be
raised when thick enhancing septations or
mural nodules are present [81]. Ultrasound
findings may suggest the diagnosis of hem-
orrhagic cyst by showing mobile septa that
are occult on CT images [80].
Traumatic Lesions
Trauma is the most common cause of he-
patic hemorrhage overall. It occasionally
A B
causes a masslike appearance or hemorrhage
into a preexisting hepatic mass. The liver is
one of the most common sites of solid organ
injury, and the most common mechanism is
blunt injury [82]. Trauma can result in a vari-
ety of injuries, including laceration, hemato-
ma, and vascular injury. The severity of inju-
ries is defined by the American Association
for the Surgery of Trauma liver injury scale,
which is the most widely used grading system
for hepatic injuries. It is important to search
for areas of active contrast extravasation,
which may necessitate endovascular therapy,
and for other associated injuries [13].
Iatrogenic causes of bleeding are another
important cause of secondary hepatic hem-
orrhage and can cause similar patterns of in-
jury. Many interventional procedures carry
risk of hepatic hemorrhage, including biop-
sy (the percutaneous approach posing greater
risk than the transjugular approach), embo-
lization or transarterial chemoembolization,
transjugular intrahepatic portosystemic
shunt, chest tube placement, percutaneous
biliary procedures, and percutaneous abla-
tion (Fig. S1). (Figs. S1–S5 can be viewed in
the AJR electronic supplement to this article,
available at www.ajronline.org.) In addition,
surgical procedures pose considerable risk,
whether from retraction injuries to the liv-
er in resection or transplant or from trocar
placement in laparoscopic procedures such
as cholecystectomy [83].
 Thomas et al.

Fig. 9—27-year-old pregnant woman with right
upper quadrant pain at 25 weeks’ gestation. Axial
unenhanced T1-weighted MR image shows large
circumscribed mass with internal hemorrhage.
Patient was treated with right hepatic artery
embolization followed by surgical resection in
postpartum period, which confirmed hemangioma.
In patients who have sustained trauma,
iatrogenic or from other sources, care should
be taken to search for underlying causes of
hemorrhage, such as a focal mass or under-
lying diffuse liver disease such as cirrhosis.
American Journal of Roentgenology
can also occur in vasculopathies such as fi-
bromuscular dysplasia and polyarteritis no-
dosa and in patients with systemic infection,
which can cause mycotic aneurysm. Pseudo-
aneurysms more commonly result from trau-
ma and liver transplant [85].
Aneurysms generally appear as a smooth
fusiform or saccular dilatation of a hepatic
arterial branch, often with a thin peripheral
calcification signifying atherosclerosis (Fig.
S3). Pseudoaneurysms are generally more ir-
regular and often are surrounded by hemor-
rhage [86]. These lesions should be differen-
tiated from arterially enhancing neoplasms.
Both aneurysms and pseudoaneurysms
carry risk of rupture. Aneurysms are usually
considered for elective repair if they are larg-
er than 2 cm in diameter or are symptomatic
[87]. Pseudoaneurysms have a high propensi-
ty for bleeding and are generally repaired en-
dovascularly regardless of size [88, 89].
HELLP Syndrome
HELLP syndrome (hemolysis, elevated
liver enzyme levels, and low platelets) is a
of maternal and fetal morbidity and mortal-
ity if the condition is left untreated. Gener-
ally, the treatment of choice is immediate de-
livery if the gestational age is greater than 34
weeks [93]. If hemorrhage is present, endo-
vascular embolization, laparotomy, or rarely,
transplant may be required [94].
Peliosis
Peliosis is a rare condition that occurs in
association with a variety of conditions, in-
cluding Bartonella infection in patients with
HIV infection, chronic wasting diseases, sol-
id organ transplant, and use of certain medi-
cations. Peliosis is usually asymptomatic and
thus is often incidentally diagnosed. Peliosis
consists of dilated hepatic sinuses that en-
large into blood-filled lacunes that may even-
tually rupture [95]. CT images may show
peliotic cavities in the liver that may contain
variable amounts of hemorrhage (Fig. S5). A
characteristic enhancing central dot (target
sign) and progressive centrifugal enhance-
ment are seen at multiphase CT and MRI.
Similar findings can be seen in other organs,

A hematoma can also be mistaken for a focal
mass, although it lacks any enhancing por-
tions (Fig. S2), and can also obscure a small
preexisting lesion [84].
Hepatic Artery Aneurysm and Pseudoaneurysm
Abnormal dilatation of the hepatic artery
can be divided into true aneurysms, which
maintain intact layers of the arterial wall,
and pseudoaneurysms, which do not. An-
eurysms of the hepatic artery are the sec-
ond most common visceral aneurysm, after
splenic artery aneurysms. The most com-
mon cause is atherosclerosis, but aneurysms
complication that occurs most often in the
third trimester or soon after birth. It is as-
sociated with severe preeclampsia [90]. It
is thought to be a placenta-induced disease
with resulting inflammation and coagulation
involving the liver. Sinusoidal thrombi cause
periportal hematoma, which can expand to
result in subcapsular hematoma or hemo-
peritoneum [91] (Fig. S4). Imaging features
in addition to hemorrhage that suggest this
diagnosis are hepatomegaly, steatosis, and
periportal edema [92].
Timely diagnosis is crucial for patients
with HELLP syndrome because of high rates
most commonly the spleen [96].
In the absence of symptoms, patients are
generally treated conservatively and moni-
tored for stability with imaging. The condi-
tion may regress with removal of the inciting
agent or infection [97, 98]. In patients present-
ing with hemorrhage, emergency endovascu-
lar or surgical therapy may be required [99].
Other Hepatic Lesions
A variety of other lesions in the liver have
been reported as rare causes of spontaneous
hemorrhage, including focal nodular hyper-
plasia, epithelioid hemangioendothelioma,

A B C
Fig. 10—83-year-old woman with abdominal pain due to hemorrhagic hepatic cyst.
A, Contrast-enhanced CT image obtained 2 years before current examination shows multiple incidentally detected simple-appearing hepatic cysts.
B, Contrast-enhanced CT image obtained after patient presented with abdominal pain shows hyperattenuating material (arrow) compatible with hemorrhage within
largest cyst. Other cysts are unchanged.
C, Doppler ultrasound image shows hyperechoic avascular material compatible with internal hemorrhage within cyst.

6 AJR:213, July 2019


biliary cystadenoma, angiomyolipoma, hepa-
toblastoma, and rhabdomyosarcoma [1]. Re-
ports of hemorrhage due to amyloid deposi-
tion within the liver have appeared, as have
reports of infectious hepatic causes, including
typhoid fever and malaria [3]. There have also
been reports of spontaneous rupture in pa-
tients with connective tissue diseases, such as
Ehlers-Danlos syndrome [100]. Patients with
cirrhosis may also experience spontaneous
hemorrhage even in the absence of HCC; re-
generative nodules, likely in combination with
coagulopathy, have been reported to hemor-
rhage spontaneously [1]. Because of the rarity
of hemorrhage with these causes, they are not
discussed in detail herein but may be consid-
ered in the appropriate clinical setting.
Conclusion
A broad spectrum of neoplastic and oth-
er pathologic conditions can result in hepatic
hemorrhage. They have the potential for dev-
astating consequences in cases of rupture,
including hemorrhagic shock, abdominal
compartment syndrome, and intraperitone-
American Journal of Roentgenology
al tumor spillage. One can often narrow the
differential diagnosis considerably by taking
into account both the imaging features and
aspects of the clinical history that may sug-
gest a particular diagnosis.
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