S2720 Hemorrhagic Shock as Initial Presentation of Hepatocellular Carcinoma: A Case Series

Abstract

INTRODUCTION: Hepatocellular carcinoma (HCC) is the fourth leading cause of cancer-related death worldwide. In the United States (US) Texas has the highest HCC incidence rate in 2015 (13.2/100,000 individuals), 45% higher than national average. Hemorrhagic shock due to tumor rupture is a rare, life-threatening presentation that requires acute intervention. Given its rare presentation, this has been documented through small case series. As such, the true impact of HCC tumor rupture on outcomes has been difficult to ascertain in different populations. CASE DESCRIPTION/METHODS: Case 1 81-year-old Hispanic man with medical history of CAD and atrial fibrillation presents to the hospital for severe right upper quadrant (RUQ) pain for 1 day. Vitals significant for BP 60/40 mmHg. On exam he is in distress with findings of acute abdomen. Hb noted at 11.4 mg/dL. CT abdomen shows a 4.1 cm mass at the posterior segment of the right lobe of the liver with perihepatic and peri-splenic fluid. Patient was initially resuscitated with normal saline and PRBCs, however he required norepinephrine and emergent trans-arterial embolization (TAE). After the procedure patient had US-guided paracentesis with 1.8 L serosanguineous fluid removal. Case 2 55-year-old Hispanic woman with Hepatitis C comes to the hospital for sudden onset severe RUQ pain. Vitals are stable, on exam has RUQ tenderness. Laboratory showed Hb 8.8 mg/dL. CT Angiography abdomen reports 3.5 cm right lobe liver mass and peri-hepatic moderate complex fluid collection. Patient received 1 unit of PRBC and went for emergent TAE of ruptured HCC. DISCUSSION: The pathogenesis behind tumor rupture remains unclear, some studies report tumor location, growth and vessels friability with high intra-tumoral pressure as a cause of bleeding and rupture. Patients present with acute abdominal pain and hypovolemic/hemorrhagic shock in 33–99% of cases. Diagnosis can be made with abdominal CT or US showing tumor location/size and hemoperitoneum if present. Paracentesis can show sanguineous peritoneal fluid. Acute management is focused on patient’s hemodynamic stabilization and bleeding control with TAE. If bleeding persists, emergency liver resection is indicated with post-operative mortality rate of 16-100%. This case series demonstrates an uncommon and life-threatening initial presentation of HCC. The high incidence of HCC among Texas-based Hispanic population warrants early recognition of this dreadful complication.Figure 1.: Case 1.CT abdomen showing 4.1 cm mass at the posterior segment of the right lobe of the liver.Figure 2.: Case 2. CT Angiography Abdominal showing arterial enhancing of a 3.5 × 3.5 cm right lobe liver mass adjacent to the lateral capsular surface. Hemoperitoneum noted.