Ruptured Hepatoma With Hemorrhagic Ascites

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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