Learning objectives:
1. Recognize hemoperitoneum as an initial manifestation of Hepatocellular carcinoma (HCC). 2. Maintain a high index of clinical suspicion for ruptured HCC in patients with cirrhosis or risk factors for cirrhosis presenting with acute abdomen.
Case:
A 72 year-old male with past medical history of ethanol abuse presented to the ED with two hours history of severe mid - back and mild right upper quadrant pain. Physical examination was notable for a blood pressure of 90/60, pulse of 130/min and mild right upper quadrant tenderness. The rest of the physical examination was unremarkable. Electrocardiogram showed sinus tachycardia with no acute ischemic changes. Rapid cardiac markers were negative. Routine laboratory work up was normal except for mild increase in aminotransferases, consistent with alcoholic hepatitis. An emergency CT scan of the abdomen, to rule out aortic dissection, revealed acute hemoperitoneum with a large ruptured hypervascular mass originating from the left lobe of the liver. The patient underwent emergent exploratory laparotomy with hemostasis and partial resection of the necrotic liver mass. Biopsy of the mass showed a moderately differentiated grade II HCC with extensive vascular invasion and chronic active hepatitis. Alpha-fetoprotein and hepatitis profile were negative. Recovery was uneventful and the patient was scheduled for chemotherapy.
Discussion:
Acute hemoperitoneum due to spontaneous rupture is an uncommon complication of Hepatocellular carcinoma (HCC). It has a very high incidence in Far Eastern countries, yet it has been reported only in 5% or less of patients with HCC in Western countries. Recently, there is an increase in the incidence of spontaneous rupture of HCC in North America secondary to the increase in immigrant population. Although the exact mechanism of spontaneous rupture of HCC is not well known, sub capsular localization, tumor necrosis, portal hypertension, and regional increase of venous pressure due to the obstruction of the venous outflow by tumor invasion have been implicated in its pathogenesis. Usually it develops in patients with an established diagnosis of HCC. However, it can also be the initial presentation as in our patient. Helical CT scan is the most useful technique for diagnosing ruptured HCC. Emergency laparotomy with partial resection of the hepatic tumor or Transcatheter arterial embolization is the treatment of choice. Early diagnosis is vital since it is a medical emergency that carries an extremely dismal prognosis and requires an aggressive therapeutic approach. Hence a high index of clinical suspicion should be maintained for spontaneous rupture of HCC in patients with cirrhosis or risk factors for cirrhosis presenting with acute abdomen.
