Acute intrahepatic bleeding in a man with focal nodular hyperplasia of the liver

History and clinical findings: A 45-year-old man had acute bouts of pain in the right lower thorax with radiation to the mid-thorax and upper abdomen. For 3 years he was known to have coronary heart disease, for 4 years arterial hypertension and for 8 months, as an accidentally discovered finding, a liver cyst 2.5 cm in diameter, as well as an inhomogeneous focal lesion, demonstrable only by sonography, lying dorsally and close to the diaphragm in the right lobe of the liver, 3.0 x 3.5 cm which was not detected by computed tomography or magnetic resonance imaging. Physical examination at admission detected epigastric pain on pressure but no other abnormalities. Investigations: Sonography showed the inhomogeneous hepatic lesion now to be 6.0 x 7.5 cm. Computed tomography demonstrated a space-occupying mass, 7.5 cm in diameter, dorsal to the hepatic cyst, partly hypo-, partly hyper-dense with marginal spotty enhancement after contrast-medium injection. Treatment and course: As acute bleeding into the focal hepatic lesion was suspected, a laparotomy was performed and liver segments VII and VIII resected. On inspection there was a sharply demarkated yellowish-white tumor with a central haemorrhagic softening. Histology revealed focal nodular hyperplasia (FNH) without signs of malignancy. Conclusion: In the case of a known but not definitively diagnosed focal hepatic lesion, acute upper abdominal pain can be a sign of acute bleeding into the lesion.