Hepatocellular carcinoma rupture with hemoperitoneum

Case contributed by Ian Bickle
Diagnosis certain


Five-day history of abdominal pain, worse for the past 3 hours. No trauma. No medical history of note. Tachycardia, hypotension.

Patient Data

Age: 60 years
Gender: Male

Non contrast due to renal impairment. Limited solid organ evaluation.

Large volume hemoperitoneum in perihepatic and perisplenic distribution as well as in the pelvis.

8 cm heterogeneous lesion in segment 6 of the liver and a 3 cm segment 7 low attenuation lesion. The former is at least partially composed of acute blood.

Aorta of normal caliber.

Remaining solid organs normal.

Comment: Hemoperitoneum - in the context of no trauma and intrahepatic abnormalities this is most likely related to a primary liver lesion such as HCC with spontaneous hemorrhage and capsular rupture.

The HU densities for the various ages of blood in the abdominal cavity on CT are shown.

Graphics courtesy of Dr Vikas Shah.

Selective celiac and SMA and super-selective right hepatic angiograms were performed.

This study shows an irregular mass in segments 6 and 7 with evidence of tumor staining and neovascularity.

There is evidence of bleeding from the segment 6 tumor with focal collection outside the liver margin.

Gastroduodenal, left gastric and splenic arteries are normal. Jejunal and ileal branches are normal.

Arterial portography shows portal vein is 1.02 cm with normal hepatopetal flow.

The right hepatic artery was embolized wih surgicel and the main artery was embolized with 4.0 mm/3.0 mm steel coil.

Post-procedure angiogram showed occlusion of the hepatic artery.

Case Discussion

One uncommon but recognized presentation of hepatocellular carcinoma is with a hemoperitoneum. Hepatocellular carcinomas are often vascular and may present late with an acute abdomen and hemodynamic instability, as in this case with a large volume hemoperitoneum.

Alpha-fetoprotein (AFP) was performed after the event and was elevated, at 28 ng/ml.

The patient underwent catheter angiography and embolization with resultant hemodynamic stabilization.

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