UNPRECEDENTED SHOCK: SPONTANEOUS RUPTURED HEPATOMA DIAGNOSED IN EMERGENCY SETTINGS

Abstract

Introduction:

Rupture of Hepatocellular Carcinoma (HCC) with intraperitoneal hemorrhage is a life-threatening condition. In patients diagnosed with HCC, rupture occurs in 3-15% with high in-hospital mortality rate of 25-75%. However, in patients without a previous history of liver cirrhosis or HCC, diagnosing a ruptured tumor remains a challenge because of the missing patient history and rarity of the disease. Here we report the case of an elderly patient with spontaneous ruptured HCC, which was detected for the first time in emergency department.
Case Report:
A 61-year-old man presented with sudden onset generalized abdominal pain and distension. He was in hypovolemic shock. Bedside ultrasound revealed massive peritoneal collection and multiple mixed echogenicity masses in the liver. It was initially assumed to be ascites caused by likelihood acute liver failure. However, in 3 hour time, hemoglobin level decreased from 11.1 g/do to 9.3 g/dl, which raised suspicions for ascites. A computed tomography (CT) angiography of the abdomen was then performed and it showed ruptured tumor with breached Glisson capsule and bleeding into the peritoneal space. Interdisciplinary discussion initiated and trans-arterial embolization was performed for hemostasis. Post procedure, hemostasis achieved, successful embolization. 

Discussion:

In this case report, we present a challenging patient who presented with acute abdomen without a prior history of liver disease and was diagnosed with ruptured HCC. For the diagnosis of a ruptured HCC, an adequate workup is often missing in the emergency room. Role of ultrasound in this case might mislead to SBP due to presence of ascites. The appearance of mixed echogenicity and sediment in the peritoneal cavity differs from the homogenous clear fluid in typical ascites. Sudden distension of abdomen within hours and hypovolemic shock relate that this patient is having active bleed. CT abdomen angiography is the confirmatory test and accurate further treatment is imminent.

Conclusion:

Challenges in establishing the diagnosis of ruptured HCC is real as absence of previous history and rarity of the presentation. Role of imaging modalities like sonography and CT must be incorporated along with clinical presentation to ensure accurate diagnosis, treatment and finally save lives.