An elderly female presented to the ER with severe abdominal pain. She underwent an evaluation including a CT of the abdomen and pelvis. The only finding was the presence of simple hepatic cyts. She was discharged from the ER. Three days later, she returned again with severe abdominal pain. A repeat CT of the abdomen was done and it showed a seemingly spontaneous rupture of one of the hepatic cysts (see image above with arrows pointing to the ruptured cyst). There was blood in the pelvis associated with this rupture.

Hepatic cysts are a relatively uncommon condition in the first place and it is even more uncommon to have spontaneous rupture of one! To briefly review, most hepatic cysts are simple or related to polycystic liver disease. Uncommon causes of hepatic cysts include hydatid (parasitic) cysts. Rare causes of hepatic cysts primary liver cancer and metastatic disease from other primaries.

If a hepatic cyst ruptures, it is usually due to trauma. The patient above vehemently denied any abdominal trauma. She also denied any violent coughing. There was a case report of a woman who ruptured a hepatic cyst after a coughing spell.

My patient was admitted and a surgical consultation was obtained. The opinion of the surgeon was that these cysts usually self-cauterize and stop bleeding on their own. My patient was hemodynamically stable and did not sustain a drop in her hemoglobin, so she was simply observed. The surgeon also said that if she did seem to re-bleed or become unstable, then the next step would be angiography to cauterize the cyst.

This patient continued to improve and did not require any intervention. It still remains a mystery as to why her cyst decided to rupture!

It seems like everybody admitted to the hospital is either on aspirin or should be taking aspirin. How soon do you restart aspirin if the patient comes with GI bleeding?

The study published in Annals of Internal Medicine addresses the issue of continuing aspirin therapy in patients admitted with peptic ulcer bleeding. All patients receive proton pump inhibitor therapy as well as an endoscopic treatment for bleeding. The patients in the aspirin group have a higher risk of rebleeding within 30 days (10.3% in aspirin group vs. 5.4% in placebo group). There is no surprise here – aspirin will increase the risk of bleeding.

The interesting finding in this study was that the patients in the aspirin treatment group had significantly lower all-cause mortality within 8 weeks (1.3% in aspirin group vs. 12.9% in placebo group). This is a very significant difference.

Obviously, the study has limitations. Small sample size (156 patients total) and single center design might skew the results of this study. Also, it would be interesting to see how treatment with aspirin effects rebleeding risk and mortality in other causes of gastrointestinal bleeding.