1. Spontaneous rupture of HCC Ruptured HCC following TACE
Department of Gastroenterology
R4 Woo Yong-Sik

2. Ruptured hepatoma with hemoperitoneum
Hemoperitoneum to non-traumatic hepatic rupture
rare but potentially fatal condition
caused by different neoplastic & nonneoplastic dz.
Malignant
Hepatocellular carcinoma
metastatic carcinoma
Benign
Cirrhosis
Hepatic angioma
Hepatic adenoma
Etc
peliosis hepatis
polyarteritis nodosa
SLE, pre-eclampsia

3. Ruptured hepatoma with hemoperitoneum
Incidence - 3~15% of pts with HCC
12.4% in Thailand, 14.5% in Hong Kong
cause of death in 10% of all pt.with HCC in japan
In western, incidence <3% in UK
mortality rate in acute phase – high, 25~75%
Clinical manifestations:
sudden onset of abdominal pain (66~100%)
hypovolemic shock (30~90%)

4. Ruptured hepatoma with hemoperitoneum - Mechanisms
rapid growth of tumor and necrosis
rupture by splitting overlying normal parenchyma or erosion of vessel
occlusion of hepatic v. by tumor thrombi
coagulopathy due to underlying cirrhosis
vascular dysfunction resulting
degeneration of elastin and degradation of type IV collagen → rendering blood vessels stiff and weak

5. Ruptured hepatoma with hemoperitoneum - Diagnosis
History of hepatoma
Typical clinical symptoms
– sudden onset of abdominal pain, peritoneal sign, shock….
Abdominal CT scan
Hepatic angiography
– extravasation of contrast from t tumor in 13.2~35.7%
paracentesis
– reliable test to confirm diagnosis positive in 86% of pt

6. J Clin Oncol 2001:19:3725~3732

7. Management of ruptured hepatoma with hemoperitoneum
Initial hemostasis
Definite treatment
Arch Surg. 2006;141:

8. Management of ruptured hepatoma -Conservative treatment
3-month survival rate of 10% and mean survival of 19.2 days
most commonly pts in moribund state and with inoperable tumor
differences between aggressive & conservative approaches : not significant
conservative treatment was used initially
→hemostatic procedure on signs of continuous bleeding
overall inhospital mortality rate (62% vs 51%)
median survival time (7 days vs 12 days)
Am J Gastroenterol. 1991;86:67-71.
Arch Surg. 1999;134:

9. Management of ruptured hepatoma -Transcatheter arterial embolization (TAE)
Total ~100% ~37%
Arch Surg. 2006;141:
1 mo. survival rate: 62% (vs 50% & 29% in patients underwent emergency operation & conservative treatment)
Am J Emer Med 2005; 23:
major life-threatening complication
- liver failure (12%-33.%), M/C cause of death after TAE

10. Management of ruptured hepatoma -surgical mangement
Perihepatic Packing
hemostasis by tamponade effect
effective especially situated near diaphragm.
intra-abdominal abscess and sepsis following packing within 72 hrs - 23% to 32%
Suture Plication
limited by friable tumor tissue
3-mo survival rate and mean survival %, and 81.5 days
Hepatic Artery Ligation
HCC supply almost exclusively from hepatic artery
hemostatic success rate - 68~100%
limited by high in-hospital mortality rate - 50~ 77%
Ann Surg. 1992;215:
Am J Gastroenterol. 1991;86:67-71.
Ann Surg. 1989;210:24-28.

11. Definite treatment of ruptured hepatoma -One stage Emergency Liver Resection vs Staged Liver Resection-
Total ~31% ~100%
Total ~56% ~9% ~100% 21.2~48% 15~21%
Arch Surg. 2006;141:

12. Ruptured hepatoma with hemoperitoneum - Prognostic factors
In multivariate analysis, independent factors on 30-day mortality
(1) shock on admission
(2) hemoglobin level,
(3) serum total bilirubin level
(4) known diagnosis of HCC before rupture
J Clin Oncol 2001:19:3725~3732

13. Ruptured HCC following TACE
Eur J Radiol 2006;59:407~412

14. Incidence of spontaneous hepatoma rupture following TACE : rare
searching for article reporting spontaneous hepatoma rupture following TACE in past 10 yrs by MEDLINE SEARCH
Two articles each reported six cases and three cases from asia
Liu CL British j surg 1998;85:
Xia Jinglin Eur J Radiol 2006;59:407–412
One article reported two cases in western
Narendra Battula Hepatobiliary Pancreat Dis int 2007;6:49-51

15. 1443 sessions of TAOE among 391 pt.
predominantly in men after first session of TOCE for large irresectable HCC of the right lobe.
British j surg 1998;85:

16. 530 sessions of TACE among 294 pt.
Large tumor size, male sex and exophytic growth of tumor may be predisposing factors for rupture.
Hepatobiliary Pancreat Dis int 2007;6:49-51

17. Huge tumor measuring 14x12cm-size in Rt. lobe Developed rupture
at 3rd post-TACE
Huge tumor in Rt. lobe
Developed rupture
at 45th post-TACE
3x3cm superficially
in Rt. lobe
Developed rupture
at same day-TACE
Eur J Radiol 2006;59:407~412

18. Predisposing factor for rupture
Spontaneous rupture of HCC
Ruptured HCC following TACE
Large sized tumor
more advanced disease
(worse clotting profile
higher serum AFP)
lower hemoglobin
less ass. with alcoholism
Large sized tumor
Rt. Lobe
Male sex
Exophytic growth of tumor
(=superficially located)
First session of TACE