Hepatocellular carcinoma rupture as a cause of spontaneous hemoperitoneum

A 80-year-old hypertensive woman with mild cognitive impairment and untreated hepatitis C cirrhosis who went to the emergency unit for nausea and general malaise after crouching at home last day. No history of direct abdominal trauma. Upon arrival, generalized abdominal pain on palpation and hypotension. Laboratory examination found anemia and hypertransaminasemia. Abdominal ultrasound revealed liver nodular contours, a focal lesion in the right hepatic lobe and abundant echogenic ascites. Multiphase abdominal CT showed abundant hemoperitoneum, advanced nodular liver and a focal lesion measuring 6.5 cm within 3rd segment with signs of active bleeding and capsular rupture. The surgery confirmed a hepatic lesion sugestive of broken necrotic tumor and hemoperitoneum. Partial hepatectomy and peritoneal cavity lavage is performed. Development of acute exacerbation of chronic renal failure (CRF) and de novo atrial fibrillation with rapid ventricular response during his stay in the intensive care unit and died 5 days after surgery.

Nontraumatic hemoperitoneum is much less frequent than traumatic hemoperitoneum. Its differential diagnosis includes iatrogenic (anticoagulation, surgical complications...) and abdominal spontaneous bleeding that may be secondary to tumors (benign or malignant), gynecological pathology (ovarian cyst rupture, ectopic pregnancy...) or vascular lesions (aneurysm and pseudoaneurysms of visceral vessels). In view of the echographic findings in our patient, we proposed differential diagnosis between spontaneous bleeding of a primary hepatic tumor given the history of cirrhosis and post-traumatic hepatic hematoma for the clinical doubt of abdominal trauma. Therefore, a multiphasic study was carried out. The spontaneous rupture of a hepatocellular carcinoma (HCC) is a rare form of presentation in western countries and is potentially fatal. It is associated with large, peripheral and highly vascularized tumors or portal thrombosis. The findings are peritumoral hematoma, hemoperitoneum, extravasation of contrast material, and tumoral capsule break (sign of enucleation). Sometimes extrahepatic feeding arteries can be identified.

The evaluation of a spontaneous hemoperitoneum requires a systematic screening of the possible causes must be done based on the patient's background, for which the urgent multiphase study is very useful.

- Takada K, Ito T, Kumada T, Toyoda H, Tada T, Sone Y, et al. Extrahepatic feeding arteries of hepatocellular carcinoma: an investigation based on intra-arterial CT aortography images using an angio-MDCT system. Eur J Radiol 2016, 85(8): 1400-6. - Shrik