Severe Anemia with Hemoperitoneum as a First Presentation for Multinodular Hepatocellular Carcinoma: A Rare Event in Western Countries

Abstract

Hemoperitoneum due to spontaneous rupture of hepatocellular carcinoma is a life-threatening and rare condition in western countries with an incidence of less than 3% because of early detection of cirrhosis and neoplasm. Here, we describe a case of a 66-year-old male patient with altered mental status with hemorrhagic shock. Computed tomography scan of abdomen revealed hemoperitoneum and mass in liver. Patient underwent resection of liver tumor and biopsy revealed multinodular hepatocellular carcinoma. A high degree of suspicion is required where severe anemia and hemoperitoneum can be a first presentation for hepatocellular carcinoma especially in patients with chronic hepatitis C infection. Early diagnosis is crucial since mortality rates remain high for untreated cases.

Figure 1

CT scan of abdomen and pelvic revealing hemoperitoneum and mass-like lesion in segment 4 of liver.

Figure 2

CT scan of abdomen and pelvic showing hemoperitoneum and mass-like density abutting gallbladder.

Figure 3

CT scan of abdomen and pelvic showing a mass at segment 5 of liver.

Figure 4

(a) H & E section (40x) shows the background normal liver cells showing mild to moderate portal triaditis and interface hepatitis (grade II) with most portal area infiltrated by many lymphocytes and few plasma cells as typical for hepatitis C. There is mild to moderate septal fibrosis that appears to be periportal and portal-portal (stage II). (b) H & E section (10x) shows multinodular hepatocellular carcinoma with fibrosis around the individual nodules. (c) H & E section (40x) shows poorly differentiated nature of the hepatocellular carcinoma with surrounding significant lymphocytic reaction.