S5436 Hemorrhagic Hepatic Adenoma in a Young Obese Woman on Long-Term Oral Contraceptives

Introduction: Hepatic adenomas are rare, benign liver tumors primarily affecting women of reproductive age. These tumors are usually asymptomatic but may hemorrhage, rupture, or, rarely, undergo malignant transformation. Hemorrhage is the most common and potentially life-threatening complication. Prompt recognition is essential in young women presenting with abdominal pain and relevant risk factors. Case Description/Methods: A 36-year-old obese woman (body mass index 39.7 kg/m²) with a 16-year history of norethindrone-ethinyl estradiol use presented with sudden, severe epigastric pain following exercise. She was hypertensive and tachycardic on arrival. Laboratory evaluation showed elevated liver enzymes (AST 152 U/L, ALT 525 U/L), mild anemia (Hb 10.6 g/dL), but otherwise unremarkable findings. Non-contrast computed tomography (CT) of the abdomen demonstrated an ill-defined left hepatic mass with hyperdense areas suggestive of hemorrhage. Magnetic resonance imaging (MRI) confirmed the presence of at least 8 hepatic adenomas, the largest measuring 11.4 cm, with evidence of intralesional and subcapsular hemorrhage. The patient underwent successful transarterial embolization of the dominant left lobe adenoma by interventional radiology. She was discharged on hospital day 4, and her estrogen containing oral contraceptive was discontinued. Two months later, she returned with recurrent abdominal pain. Surgical consultation was obtained, and she underwent laparoscopic hand-assisted left lateral segmentectomy, partial right lobe resection (segments VI/VII), and cholecystectomy. Histopathology confirmed hepatic adenomas. Her postoperative course was uneventful, and she remained asymptomatic at the one-month follow-up. Discussion: This case highlights the hemorrhagic risk associated with multiple hepatic adenomas in the setting of long-term estrogen exposure and obesity. Hemorrhage occurs in up to 30% of cases and is the most common serious complication. MRI remains the preferred imaging modality for diagnosis and surveillance. While transarterial embolization is an effective initial intervention for hemodynamically stable patients with active bleeding, recurrent symptoms and high lesion burden may necessitate surgical resection for definitive management. This case reinforces the importance of early cessation of hormonal therapy and the role of a multidisciplinary team, including hepatology, radiology, and surgery, in optimizing outcomes for high-risk patients.