Liver Tumor Complicated by Bleeding. How to Manage This and What Are the Treatment Options ?

Liver Tumor

In about less than 10% of liver tumors, abdominal bleeding can be encountered as part of the cancer progression or cancer complications.  The abdominal bleeding (secondary to liver tumor rupture/crack) can be major/massive and can be life threatening.  Many patients present to the emergency department with significant abdominal pain, syncope, low blood pressure, and sometimes loss of consciousness.  This condition needs to be promptly diagnosed and treated upon diagnosis.  Hepatocellular carcinoma liver cancer and hepatocellular adenoma (hepatic adenoma) can both cause major bleeding from a tumor rupture into the abdominal cavity.  When the large tumors are located on the periphery of the liver (near the liver surface or liver capsule), spontaneous bleeding is more likely to occur.  Deeply located tumors within the liver parenchyma are less likely to bleed bleed.  Liver tumor bleeding can be triggered by a minor trauma such as car accident, fall, or sports injury.  The larger the tumor, the more friable it is any the more easily for it to bleed.

In the immediate phase of treatment, the bleeding from the liver tumor needs to be stopped.  The patient may need to have blood transfusion to replace the ongoing blood loss.  An interventional radiology technique via the hepatic artery selective embolization is needed.  During this procedure, a groin puncture is done to insert a small catheter into the aorta and finally into the hepatic artery feeding the liver tumor.  A small amount of intravenous contrast dye is injected to evaluate presence of active bleeding.  Once confirmed, small embolization particles are released to occlude the network of blood vessels/capillaries going into the tumor or bleeding area.  This type of specialized service is usually only available at a tertiary liver cancer program or a liver transplant center.  Most community hospitals do not have the expertise available 24/7.  Any immediate transfer is mandatory to save the patient’s life.  Our liver cancer program/liver cancer center is fully equipped to handle this type of emergency in Tampa Bay Area.

Once the bleeding is controlled by the hepatic artery embolization, the patient should be observed in the hospital for possible rebleeding.  Intensive care unit admission is appropriate in this circumstance.  The rebleeding rate is reported between 10-30% in the literature.  Once the patient is hemodynamically stable, a semi-elective surgical liver resection to remove the source of bleeding (the liver tumors itself) needs to be performed.  Most patients have the liver resection performed within 2 weeks of the initial bleeding event.  Open or minimally invasive liver surgery can be utilized, depending on the technical expertise of the operating team.  Dr. Iswanto Sucandy and his colleagues have performed robotic liver resections for bleeding liver tumors.  During this operation, significant blood clots around the liver usually need to be evacuated to expose the surgical field.  The source of the bleeding may also need to be temporarily packed to avoid a free tumor rupture or further rebleeding.  The liver resection is then started by controlling/ligating the vessels feeding the tumor.  Once the tumor is completely resected, the chance of recurrent bleeding episode from the reminder of the liver parenchyma is essentially nonexistent.

Diagnosis of bleeding liver tumor is rare but life-threatening, therefore, an early diagnosis and treatment are very important.  Findings of subcapsular bleeding around the liver tumor should prompt an urgent visit for an evaluation by a liver surgeon or a liver specialist.  A CT scan with intravenous contrast is typically performed to confirm or rule out the diagnosis.  It is important to prevent bleeding complication from any liver tumors before it happens.  Hepatic adenoma larger than 4 cm should be resected to avoid bleeding complication.  Hepatocellular carcinoma should be resected when the liver function is preserved.  A large subcapsular liver hemangioma can also theoretically bleed after significant physical trauma.  Dr. Iswanto Sucandy and his colleagues are the referral center /providers for liver tumors in Tampa Bay Area and beyond.

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