Simple hepatic cyst rupture exacerbated by anticoagulation

Simple hepatic cysts are usually asymptomatic but can rarely result in life-threatening complications such as haemoperitoneum secondary to rupture. A 70-year-old woman with known simple hepatic cyst presented with acute chest pain and dyspnoea. The initial diagnosis was pulmonary embolism, and anticoagulation was commenced. However, she subsequently collapsed with haemodynamic instability. CT revealed a large hepatic cyst haematoma with rupture into the peritoneal cavity. The patient underwent emergency laparotomy, haemostasis and partial deroofing of the cyst. Retrospective review of CT scans suggested that the bleed had begun on presentation but was exacerbated by anticoagulation. To our knowledge, this is the first report of haemorrhagic hepatic cyst associated with acute anticoagulation. We discuss several important clinical lessons including cyst rupture as a possible cause of chest pain, the need for careful review of imaging and the choice of anticoagulation in patients with known simple hepatic cyst.