A 61-Year-Old Woman With Abdominal Pain and Syncope

James J. McCombie, MB ChB; Erik D. Schraga, MD


June 01, 2016

Spontaneous rupture of a hepatoma is potentially life-threatening. The lifetime incidence of rupture is < 3% in patients with a diagnosis of hepatoma in Western countries; however, mortality was reported as being close to 50% among Asian patients in another series, where the incidence of hepatoma is as high as 12%-14%.[4]André[5] first reported hemoperitoneum associated with the rupture of primary hepatic tumors in 1851. Rupture is preceded by a rapid increase in the size of the tumor from bleeding within its substance.[6]

Any patient with known cirrhosis or hepatoma who presents with acute abdominal pain, particularly when associated with hypovolemia or evidence of peritoneal free fluid, should be approached with suspicion of hepatoma rupture. The diagnosis may be made by ultrasonography, CT, or angiography. When imaging is not readily available, deep peritoneal lavage can be performed as an alternative. In the absence of trauma, hemoperitoneum in a patient with a history of cirrhosis should be considered highly likely to have resulted from hepatoma rupture. Many cases, however, are diagnosed at laparotomy.[7]

Broadly speaking, three avenues of treatment exist: transcatheter arterial embolization (TAE), hepatectomy, and conservative management. In the acute phase, TAE for hemostasis has a high success rate (53%-100%). It has a lower 30-day mortality rate than open surgical methods (0-37% vs 28%-75%).

For definitive treatment, staged liver resection has a higher resection rate (21%-56% vs 13%-31%) and a lower in-hospital mortality rate (0%-9% vs 17%-100%) than one-stage emergency liver resection. Staged liver resection has a good survival rate (1 year, 54.2%-100%; 3 years, 21.2%-48%; 5 years, 15%-21.2%).[7,8]Emergency hepatectomy should be reserved for patients with an easily resectable lesion who are in a stable cardiovascular condition.

Conservative therapy may be used for selected patients in extremely poor condition. The recommended treatment for most patients with ruptured HCC is TAE, followed by hepatectomy (if the lesion is resectable).[8]

As long as a patient with rupture undergoes TAE and the tumor is amenable to resection, survival rates are good. In one study, cumulative survival rates at 1, 5, and 10 years among patients treated with elective hepatectomy after ruptured hepatoma and initial TAE were 90.0%, 67.5%, and 20.3%, respectively.[8]However, reports have described intraperitoneal seeding of hepatoma after rupture occurring as early as 3 months after the event.[9]

Sorafenib, an inhibitor of several protein kinases implicated in carcinogenesis, was approved by the US Food and Drug Administration for the treatment of advanced HCC in 2007. Results from the Sorafenib Hepatocellular Carcinoma Assessment Randomized Protocol (SHARP) trial demonstrated an increase of 3 months in both median survival time and time to radiographic progression of the lesion in patients given sorafenib over placebo.[10]


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