A case of acute abdomen caused by ruptured bifocal HCC

Clinical History

An 85-year-old female patient was admitted to the Emergency Department for severe right hypochondrial pain, abdominal distension and hypovolaemic shock with haemoglobin concentration of 6.5 g/dL. The patient was HCV positive and had no history of trauma.
A Computed Tomography (CT) of the abdomen was performed.

Imaging Findings

CT images performed before injection of contrast medium revealed free peritoneal fluid with higher attenuation in the right subhepatic space (Fig.1). After injection of contrast medium two heterogeneous capsulated hepatic nodules were seen in III and VI segments (Fig. 2a, 2b, 3), showing intralesional active extravasation of contrast medium (Fig. 2a). The nodule of the VI segment presented contextual peripheral hypodense area, suggesting the point of rupture through the liver capsule, with adjacent active intraperitoneal bleeding (Fig. 2b, 2c, 3). The diagnosis of bifocal ruptured hepatocellular carcinoma with active bleeding was made and then confirmed at surgery (Fig. 4) and histology (not available).

Discussion

Hepatocellular carcinoma (HCC) rupture is a rare and life-threatening event, representing one of the causes of non-traumatic spontaneous haemoperitoneum and the most common cause of non-traumatic hepatic haemorrhage [1]. It is considered one of the most rare complication in patients with HCC, occurring only in 3-15% of cases, with a lower incidence reported in western centres compared with Asian centres [2, 3]. Clinically it manifests with abdominal pain and with signs and symptoms related to hypovolaemic shock [2]. The prognosis is poor, and the hospital mortality rate ranges from 33 to 67% [4].
Risk factors are considered to be great dimension, protrusive aspect of the nodule beyond the margin of the liver, portal vein thrombosis, cirrhosis and hypertension. The most acknowledged theory about the mechanism of rupture is that of invasion and occlusion of the hepatic veins by tumour cells, resulting in increased pressure within the tumour mass. However, some authors have shown that an important predisposing factor is tumour location in II, III and VI segments, because of their small volume area restricted by the capsule, which can be broken by the tumour when it becomes larger [5]. This is interesting to consider related to our case, consisting in bifocal protrusive HCC located in III and VI segments.
Imaging plays an important role in diagnosis of rupture of HCC, allowing prompt treatment. CT is the most-used method in the emergency department, therefore often the diagnosis of HCC rupture is made through this technique. On unenhanced CT it is possible to identify haemoperitoneum, with a haematic clot usually located near the site of bleeding [1]. The presence of haemoperitoneum on CT scan in atraumatic patients with known HCC and acute abdomen is strongly suspected for ruptured HCC. However, enhanced CT images are essential to recognize the site of bleeding, represented by active extravasation of contrast medium. Moreover, enhanced CT allows a better detection of the HCC, which may show contextual areas of fluid collection representing the point of rupture, and allows to stage the disease.
In case of HCC rupture there are three options of treatment: conservative, transcatheter arterial embolization (TAE) and liver resection, depending on the patient's conditions (stable and unstable) and liver function [6].
Our patient didn't present liver dysfunction and contraindications to surgery, so she underwent emergency double wedge resection. On surgical exploration the nodule of the VI segment clearly shows focal interruption, corresponding with the hypodense subcapsular area shown on CT.

Differential Diagnosis List

Final Diagnosis

Rupture of bifocal hepatocellular carcinoma with active bleeding

URL:	https://www.eurorad.org/case/14064
DOI:	10.1594/EURORAD/CASE.14064
ISSN:	1563-4086