Discussion

Teratomas are germ cell neoplasms that are characterized by a foci of abnormal tissue growth derived
from the three germinal layers. They occur most commonly in the ovaries, testes, retroperitoneal and
sacrococcygeal regions. Less commonly, there are case reports where teratomas have risen from the
gastrointestinal tract and rarely, from the liver. [1] Such cases usually present with a palpable abdominal
mass, distension and site-specific mass effects to adjacent structures.

Liver teratomas are extremely rare. An extensive literature review yielded less than 50 cases of primary
hepatic teratomas. Most of them are encountered in patients <3 years of age, are more common in
female patients and involve the right lobe of the liver. [2]

A sufficiently large teratoma arising from the liver could explain the constellation of signs and symptoms
seen in our patient. Mass effect from the tumor will compress adjacent vascular structures eventually
leading to portal hypertension. This condition classically leads to ascites and esophageal varices. The
former wasnt explicitly stated in the patients physical findings, but the group believes that this is
masked by the large mass occupying the abdomen. This was further aggravated by decreased albumin
production brought about by the hemodynamic derangements. Mild elevations in Aspartate
aminotransferase enzymes are also seen in our patient, reinforcing the likelihood of invasive liver
disease. Reactive leukocytosis, anemia and elevated Lactate dehydrogenase could signify malignancy, all
of which are seen in our patient. LDH elevations in particular, signify rapid cell division in the tumor
which is probably what is happening in the patient.

The eventual demise of our patient is postulated to be a result of the formation of esophageal varices
and their subsequent rupture. This is the main source of bleeding within the GI tract that explains the
presence of occult blood in the stool. Furthermore, this would explain the gross blood found in the
patients mouth on the 3rd hospital day and melena and coffee ground material on the orogastric tube
several hours after that. Hypotensive shock was apparent, and asystole followed which eventually lead to
death of the patient.

Final diagnosis Hypotensive shock due to bleeding of esophageal varices secondary to portal
hypertension secondary to a hepatic teratoma causing mass-effect

1 - http://pubs.rsna.org/doi/full/10.1148/rg.245035209
2 - Rahmat K, Vijayananthan A, Abdullah Bjj, Amin Sm. Benign teratoma of the liver: a rare cause of
cholangitis. . http://europepmc.org/abstract/MED/21614237. Biomed Imaging Interv J. 2006;2(3) doi:
10.2349/biij.2.3.e20