Acute hemoperitoneum after ruptured hepatocellular carcinoma: First Moroccan SCARE-compliant case report and literature review

Highlights • Acute hemoperitoneum after a spontaneously ruptured hepatocellular carcinoma (HCC) is a rare complication.• In cases with stable conditions, imaging guided by computed tomography (CT) enables arterial embolisation.• Surgery is a choice after failure of embolisation or in case of severe hemodynamic instability.• The prognostic outcomes of ruptured HCC depend mostly on the underlying liver function.• Successful management by one-stage surgery allowed radical treatment of this rare entity.


Introduction
Ruptured HCC is relatively rare in developed countries and occurs to approximately 3-26% of HCC patients [1][2][3]. Acute abdominal pain is the major clinical symptom that reveals this association in 97% of cases [4]. It was suggested that tumor necrosis, rapid growth as well as vascular erosion and occlusion of hepatic veins are the most important clinico-pathologic features that influence the intra-tumor pressure and therefore the pathogenesis of this entity [5]. Notably, ruptured HCC leads to hemorrhagic shock which is the main severe issue that influences prognosis [2]. Recent case series consider first-line embolization followed by elective hepatectomy as an effective therapeutic strategy for the management of this fatal entity [6]. However, surgery alone for peripheral lesions of patients with adequate hepatic functions (Child-Pugh score A and B) is also valuable [6]. Moreover, the underlying liver's function is a key parameter that helps in predicting prognosis of ruptured HCC [7]. We report, to the best of our knowledge, the first case of an acute hemoperitoneum with a ruptured peripheral and fortuitously discovered HCC in an 81-year-old woman man-aged successfully by a one-stage surgery in Morocco. This work has been reported in line with the SCARE criteria [8].

Case presentation
An 81-year-old woman, from eastern Morocco, was admitted to the emergency department following a sudden manifestation of abdominal pain associated with significant distension and increased hypotensive shock with a decrease of blood pressure by 42%. The patient was under oral treatment for diabetes and hypertension and was suffering from no previous diseases. In this regard, laboratory parameters showed hemoglobin level of 5 g/dl and thrombocytopenia of 65,000 elements/l. Diagnostic ultrasound and CT scan showed a rounded and hyper-vascular nodular formation of 37.44 mm in hepatic segment III with heterogeneous enhancement and individualization of an arterial "blush" which was elevated in the left portal vein that is associated with hemoperitoneum of great abundance (Fig. 1). Following radiological diagnosis, she was transferred to the surgery department for exploration and to maintain the intraoperative hemodynamic stabilization that was ensured at the same time using the transfusion of red blood cells and fresh frozen plasma. Segment III tumor bleeding was detected and 3 liters of blood were collected during laparotomy exploration. Then, a segmentectomy III (    status, without undesirable events. Histopathological analysis of the surgical resection specimens revealed a well differentiated HCC (Edmondson-Steiner grade II, pT4) developed on cirrhosis with the presence of a regeneration of liver nodules and unaffected margins (Fig. 3). Postoperative period was smooth and uneventful, and the patient left the hospital on the 5th postoperative day.

Discussion
According to the latest data from GLOBOCAN 2018, liver cancer, which is dominated by HCC (75%-85% of cases), is the fourth cancer leading to high mortality after lung, colorectal and stomach cancers [9]. In Eastern Morocco (place of origin of our patient), liver cancer is the sixth digestive cancer in terms of incidence [10]. As suggested by a recent systematic review encompassing more than 4900 cases, rupture of HCC is mostly due to patients and tumor specific characteristics including older age, large tumor sizes, portal hypertension and advanced cirrhosis [11]. Acute abdominal pain is the constant sign of ruptured HCC in addition to peritoneal irritation and haemodynamic instability [7]. Acute hemoperitoneum is commonly diagnosed due to ruptured peripherally located HCC such as in our case [7]. Moreover, hypotensive shock may also be seen in a tangential anatomical presentation contrary to centrallocated HCC in which bleeding is not frequent. In patients with no history of liver diseases, ruptured HCC is often diagnosed during exploratory surgery [4]. Until this time, CT scan still plays a key role in determining the origin of active bleeding and extravasation as well as the location and size of associated hepatic tumors [5,6]. Control of bleeding and shock status by haemostatic procedures and transfusion are required and considered as being major factors to survive after a ruptured HCC. Data from large retrospective cohorts [11][12][13][14][15][16] (summarized in Table 1) suggest that transarterial embolization (TAE) is the best haemostatic treatment for patients with unstable hemodynamic status. In addition, unstable ruptured HCC patients diagnosed during laparotomy benefit from surgical hepatic resections and artery ligation which are useful homeostatic practices with various rates of in-hospital mortalities [5,[11][12][13][14][15][16]. However, most of these studies reporting single center experiences were retrospective in their design and no randomized and controlled trials were conducted to determine the optimal method for treating ruptured HCC. Our case of ruptured CHC is radiologically suspected in the absence of any known CHC risk factor. After histopathological examination and the confirmation of HCV infection, the patient was treated and recovered favorably. Of note, improved survival of ruptured HCC patients may be achieved after liver tumor resection, and the key factor of poor prognosis is the initial hemodynamic status as well as the underlying liver's function [6,13]. In conclusion, ruptured HCC should be suspected in patients with acute hemoperitoneum when no risk factor of liver diseases is found.

Sources of funding
None.

Ethical approval
Not required for this case report.

Consent
The patient gave written permission to publish her case findings.