図１〜図３で低濃度の，不整に造影される病変があり（↑；実は肝実質内血腫），肝周囲の※は不整な構造を示し血腫を含む腹水であろう．▲は血管と同濃度を示すのでextravasationであり，肝腫瘍破裂の所見である．肝周囲の血腫は肝実質を圧排しており被膜下血腫を示唆するが，脾臓背側にも腹水がある（△）．胆管細胞癌の破裂と診断し血管造影（図A ）を行った．腫瘍を示唆する所見はないが，extravasationを認め（↑）TAEを施行したが，それ以上の積極的な治療を希望せず3日後に再出血を起こし死亡した．病理解剖で肝右葉破裂による腹腔内出血（860ml）と大腸壊死を認めた．肝臓に腫瘍性病変はなく特発性破裂による被膜下および実質内血腫（図Bと図C：白矢印）と診断された．

参考症例（膵臓癌肝転移腫瘍の被膜下破裂）：72歳男性．急に発症した心窩部痛で来院．肝臓に転移性腫瘍と思われる多発性の病変があり，↑は膵腫瘍を示し，※は転移性病変の被膜内破裂と思われる．経皮的ドレナージで血性内容液が排出された．

文献考察１）：肝自然破裂70例．病変は肝細胞癌85.7%，腺腫5.7％，肝硬変4.3%，血管腫2.9%，転移性癌1.4％．
World J Gastroenterol. 2002 Dec;8(6):1063-6.
Etiology and management of hemmorrhage in spontaneous liver rupture: a report of 70 cases.
Chen ZY, Qi QH, Dong ZL.

AIM: To analyze the causes and management of hemorrhage in spontaneous liver rupture. METHODS: Seventy cases of spontaneous liver rupture were retrospectively analyzed for causes of hemorrhage and therapeutic effects of surgical approaches. RESULTS: It was demonstrated that the causes of spontaneous liver rupture were primary liver cancer in 60 cases (85.7 %), cirrhosis in 3 cases (4.3 %), liver angioma in 2 cases (2.9 %), liver adenoma in 4 cases (5.7 %),and secondary liver cancer in 1 case (1.4 %). Hemostasis was achieved with surgical approaches in 68 cases (97.1 %) and non-surgical approaches in 2 cases (2.9 %). Surgical interventions included suture, ligation of hepatic artery, hepatic artery chemoembolization and partial hepatic resection. CONCLUSION: The results suggest that surgical intervention is still the main therapeutic method and the best procedure that should be selected according to causes of disease and patient's condition and history.PMID: 12439926（full text）

文献考察２）：肝自然破裂例は上記疾患以外に，限局性結節性過形成，抗凝固剤服用者，子癇に伴うHELLP（Hemolysis，Elevated Liver enzymes，Low Platelets）症候群，SLE，rheumatoid arthritis，amyloidosisなどの報告があるが，症例は胆管炎から胆汁うっ滞→肝浮腫と腫大が原因で自然破裂したものと思われた．
G Chir. 1993 Sep;14(7):349-50.
Spontaneous rupture of the liver.
Celoria G, Coe NP, Falco E, Nardini A.

A case of spontaneous hepatic rupture associated with bacterial cholangiohepatitis, an entity not previously described as an etiologic factor, is reported and the literature reviewed. Awareness of the pathophysiology of this process and avoidance of certain procedures are important parts of the surgical armamentarium.PMID: 8286177