Ruptured Hepatoma With Hemorrhagic Ascites

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A 57-year-old man presented with a 3-day history of increasing abdominal girth, fatigue, and light-headedness without melena or hematemesis. His medical history was significant for Laënnec cirrhosis, chronic hepatitis C, and a recent admission for alcoholic hepatitis with variceal hemorrhage. On presentation, the patient's Model for End-stage Liver Disease score was 32 (international normalized ratio, 2.6; total bilirubin level, 6.7 mg/dL, serum creatinine level, 2.2 mg/dL), with a hematocrit of 16.1% (hemoglobin level, 5.6 g/dL). After appropriate resuscitation, a diagnostic paracentesis was performed, revealing hemorrhagic ascites. An emergent liver magnetic resonance image was obtained, which showed a 4.9-cm necrotic mass (Figure, large arrow) with an extrahepatic extension of heterogeneous signal intensity (Figure, small arrow) that layered in a dependent fashion (Figure, arrowheads) consistent with acute hemorrhage. The patient was managed with arterial embolization via interventional radiology and continued blood product support. His serum alpha-fetoprotein level was 4270 ng/mL, confirming the diagnosis of hepatocellular carcinoma (HCC). The patient was deemed not to be a suitable liver transplant candidate and was discharged to home in stable condition on hospital day 8. The patient had repeat radiologic embolization as an outpatient with no further bleeding complications.

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The spontaneous rupture of HCC is an infrequent yet severe complication that is associated with a high mortality rate.¹ This complication is common in some parts of Asia and Africa, where more than 10% of HCC patients present as acute hemoperitoneum owing to spontaneous rupture of the tumor. However, in Western countries, this is a rare occurrence.² Complications arise owing to the difficulty of diagnosis because the clinical presentation can vary greatly. Our patient presented with worsening ascites, abdominal pain, and anemia, with diagnostic paracentesis revealing hemorrhage into the peritoneum. One study found most patients presented with abdominal complaints, anemia, shock, and signs of acute peritonitis.³ The management of a ruptured HCC often is complicated by the poor physical condition of the patient with limited treatment modalities available. Treatment options include emergent surgical hemostasis, arterial embolization, tumor resection, or conservative therapy such as hospice care.¹ Despite therapy, the prognosis is poor, especially among those who only receive conservative treatment or emergent surgical hemostasis. Arterial embolization and tumor resection appear to have a survival advantage.¹ In conclusion, ruptured HCC should be considered in the differential diagnosis of hemorrhagic ascites.

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References 

1. Wang B, Lu Y, Zhang XF, et al. Management of spontaneous rupture of hepatocellular carcinoma. Aust N Z J Surg. 2008;78:501–503
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2. Chedid AD, Klein PW, Tiburi MF, et al. Spontaneous rupture of hepatocellular carcinoma with haemoperitoneum: a rare condition in Western countries. HPB (Oxford). 2001;3:227–230
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3. Chen ZY, Qi QH, Dong ZL. Etiology and management of hemorrhage in spontaneous liver rupture: a report of 70 cases. World J Gastroenterol. 2002;8:1063–1066
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