Fatal intra-hepatic haemorrhage presenting with cardiac-type chest pain and anaemia

A 79-year-old woman presented to the accident and emergency department with a short history of central chest pain radiating to the arm and epigastrum, associated with vomiting. There was no history of haematemesis and no recent change of bowel habit or melaena. She had a myocardial infarction 4 months previously and had a metal prosthetic mitral valve replacement for which she was anticoagulated with warfarin, maintaining an INR between 2.5– 3.5. On examination she appeared pale, but there were no other abnormal findings; the liver was not enlarged or tender.