A 32-year-old woman on combined oral contraceptives for 12 years presents with acute right upper-quadrant pain and hypotension. Ultrasound shows a 6 cm well-defined heterogeneous hyperechoic lesion in the right lobe with peripheral vascularity. The structure marked **A** in the diagram demonstrates arterial enhancement on multiphase CT followed by isodensity in the portal venous phase, with signal drop on out-of-phase MRI imaging. Which of the following is the most appropriate IMMEDIATE management for this patient?

Why Emergency angiographic embolisation and cessation of oral contraceptives is right

The structure marked A is a hepatocellular adenoma — a benign but vascular lesion prone to hemorrhage and rupture, especially when >5 cm. The clinical presentation of acute RUQ pain and hypotension in a young woman on OCPs is the classic emergency scenario of intra-tumoral or intra-peritoneal hemorrhage from an adenoma. The imaging findings (arterial enhancement, isodensity in portal venous phase, intracellular fat on out-of-phase MRI) are pathognomonic for hepatocellular adenoma. In the acute setting with hemodynamic instability, emergency angiographic embolisation is the life-saving intervention to control bleeding, followed by cessation of the estrogenic stimulus (OCPs) and definitive surgical resection once stabilised. Per EASL and AASLD guidelines, hemorrhaging adenomas require urgent intervention.

Why each distractor is wrong

EASL Guidelines on Benign Liver Tumors; AASLD