We refer the case of a 73-year-old female patient who consulted for jaundice and constitutional syndrome of less than 2 months' duration. In the emergency department there was evidence of a large painful hepatomegaly and analytical tests showed leukocytosis with neutrophilia and mixed alteration of the liver profile, predominantly cholestatic (alkaline phosphatase and GGT more than 10 times the normal value and ALT and AST less than 3 times the normal value), without hepatic insufficiency.

Twenty-four hours after admission, he began with confusional symptoms that rapidly progressed to coma and fever of over 39ºC. An abdominal ultrasound and CT scan were performed, showing multiple space-occupying, hypodense, solid liver lesions distributed in both lobes and occupying practically the entire organ, suggestive of MTS. No infectious focus was found, several blood cultures were sterile and, by CT, the presence of brain lesions had been ruled out.

Analytically, the liver profile deteriorated, presenting a significant elevation of transaminases in the range of acute hepatitis (ALT and AST greater than 20 times the normal value with a significant increase in LDH) and signs of liver failure with progressive deterioration of renal function.
Despite intensive treatment with anti-encephalopathy measures, vasoactive drugs, broad-spectrum antibiotics at high doses (to cover the CNS as a possible focus) and transfusion of fresh frozen plasma, the patient died 5 days after admission as a result of multi-organ failure, without establishing the nature of the liver lesions or their origin due to the rapid evolution. For this reason, a clinical autopsy was performed.
The necropsy confirmed the existence of extensive hepatic MTS. The primary tumour was a caecal adenocarcinoma 3 x 2 cm in diameter, Dukes stage D and Astler-Coller stage IV. It had serous and perivascular fatty infiltration and lymphatic and venular infiltration. MTS in locoregional infradiaphragmatic lymph nodes and lung parenchyma. In addition, lesions of associated ischaemic hepatitis and cholangiolitis and extensive pancreatic and peripancreatic autolysis were observed.