Hepatocellular carcinoma with hemoperitoneum due to direct tumor invasion of right hemidiaphragm

Case contributed by Marta Duczkowska
Diagnosis certain


Referred from another center due to sudden onset abdominal pain. History of alcoholic liver cirrhosis. No trauma.

Patient Data

Age: 70 years
Gender: Male

Liver shows features of cirrhosis.  There is a 10cm heterogenous tumor in the right liver lobe with macroscopic fat and faint enhancement.  Suspicion of another 2.5 cm lesion in segment 3. Smaller hypodense lesions up to 1.5cm in right liver lobe consistent with cysts. Remaining solid organs normal.

Moderate volume hemoperitoneum surrounding the liver and tracing down paracolic gutters and pelvic region. 

The study confirms the presence of a large tumor in right liver lobe with impression of the right hemidiaphragm. The presence of fat within the lesion is visible on fat saturation images. The lesions shows heterogenous enhancement and the presence of a capsule. Features consistent with HCC. A 2.5cm LIRADS 4 lesion is visible in segment 3. Liver cysts. Smaller amount of peritoneal fluid.

Signs of liver cirrhosis. Liver cysts. No additional liver lesions.

Case Discussion

Tumor rupture occurs in 3-15% of patients with hepatocellular carcinoma (HCC) and is a life-threatening complication 1. Direct diaphragmatic involvement is found in ~13% of patients with HCC 2.

The patient underwent hemostatic surgery and revealed invasion of the diaphragm by the tumor, a probable source of bleeding.

Liver fragments obtained confirmed poorly differentiated hepatocellular carcinoma (G3) on histology. Interestingly, the patient’s AFP level was only 4.55 IU/mL (ULN 5.8 IU/mL).

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