Hepatic endometriosis causing hemoperitoneum in a woman with deep endometriosis

Hepatic endometriosis is a rare extrapelvic manifestation that can mimic hepatic neoplasia and, exceptionally, cause hemoperitoneum. We report a 45-year-old nulligravid woman with longstanding deep endometriosis and anticoagulation for cavoiliac deep venous thrombosis who presented with severe right lumbar pain and signs of peritoneal irritation. Computed tomography showed a 127 × 120 × 112 mm heterogeneous subcapsular and parenchymal lesion in hepatic segments VI-VII, with hyperattenuating ascites compatible with hemoperitoneum. Magnetic resonance imaging demonstrated a solid-cystic lesion with T2 hyperintensity, intrinsic T1 hyperintense blood products, and heterogeneous enhancement, together with bilateral hemorrhagic adnexal endometriotic lesions. After temporary interruption of apixaban, vena cava filter placement, and phrenic artery embolization, multidisciplinary surgery evacuated approximately 1.5 L of hemoperitoneum and controlled bleeding from ruptured hepatic endometriotic tissue. Histopathology confirmed hepatic endometriosis. Recognition of hemorrhagic imaging features in the context of deep endometriosis is essential to avoid misclassification as malignancy and guide timely multidisciplinary management.