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A 21 year old man was admitted with three episodes of recurrent haematemesis and colicky right upper quadrant abdominal pain. After the first bleed he developed jaundice, which was short lasting. This was associated with fever, chills, and rigors. There was a history of blunt trauma to the right chest a month before this admission. Subsequent to the injury he had had recurrent pain localised to the epigastrium and the chest and he was managed with non- steroidal anti-inflammatory drugs. He was a smoker and had also consumed 50 g of alcohol almost every day, for the last five years.
On examination, the patient was pale with mild icterus. His liver was moderately enlarged and tender. Investigations showed a haemoglobin of 80 g/l, and bleeding and clotting times and chest radiography were normal. Liver function tests showed a serum bilirubin 85.5 μmol/l, direct bilirubin 53.3 μmol/l, aspartate aminotransferase 223 IU/l, and alanine aminotransferase 164 IU/l. Ultrasound with Doppler showed a large 5 × 7 cm irregular well defined predominantly hypoechoiec lesion in the right lobe of the liver with a pulsatile vessel in the rim simulating a pseudoaneurysm.