Gastrointest Radiol 17:170-172 ( 1992~

Gastrointestinal

Radiology 9 Springer-VerlagNew York Inc. 1992

Ruptured Hepatoma: Detection with Lipiodol Angiography Pyo Nyun Kim, 1 Kyung Soo Lee, ~ and Seong Gyu Whang 2 Departments of ~Diagnostic Radiology and 2Internal Medicine, Soonchunhyang University Hospital, Choongnam, Chunan, Korea

Abstract. Hemorrhage from ruptured hepatoma is a serious complication. Transcatheter arterial embolization (TAE) is a choice of the treatment for control of hemorrhage. But conventional angiography may be useless for detection of bleeding site from ruptured hepatoma. We report two cases of ruptured hepatoma with detection of bleeding site by Lipiodol angiography. Key words: Liver, h e p a t o m a - - Liver, ruptured hepatoma - - Angiography, Lipiodol angiography.

Ultrasonography (US) showed a bulging mass on the surface of the liver and ascites, suggesting ruptured hepatoma. Hepatic angiography showed abnormal contrast pooling from the anterior segmental branch of the right hepatic artery (Fig. 1A). TAE with 10 ml of Lipiodol Ultra-Fluide (Laboratoire Guerbet, France), 50 mg of Adriamycin (Adria, Dubin, OH, USA), and a small quantity of Gelfoam (Upjohn, Kalamazoo, MI, USA) was performed. During the injection of the mixture of Lipiodol and Adfiamycin, Lipiodol accumulated at the site of contrast pooling and freely moved into the peritoneal cavity under the fluoroscopy (Fig. IB). One month later, a plain film of the abdomen showed accumulation of Lipiodol in the right lower quadrant (Fig. IC).

Case 2

Ruptured hepatoma is usually fatal, especially in patients with underlying liver cirrhosis, because surgical treatment or management of bleeding is difficult in most of these cases [1]. Transcatheter arterial embolization (TAE) has been used as an effective, lifesaving, therapeutic procedure for ruptured hepatoma [2-4]. However, detection of a ruptured site in hepatoma by hepatic angiography is difficult especially in cases of multinodular or massive hepatoma. We describe our experience with Lipiodol angiography for detection of ruptured hepatoma.

A 57-year-old man presented with sudden onset of abdominal pain and distention. He had been complaining of abdominal pain for 1 year. Physical examination revealed icteric sclera, palpable liver below the subcostal margin about three fingers in breadth, and tenderness in the entire abdomen. Paracentesis yielded bloody ascites. AFP was increased, 3000 ng/ml in serum and 3000 ng/ml in ascites. US showed an echogenic liver with a lobulated contour and ascites. Computed tomographic (CT) scan showed multiple round low-density masses in the right lobe of the liver and ascites, with relatively high-density areas suggesting recent hemorrhage (Fig. 2A). Hepatic angiography showed multiple hypervascular masses in the fight lobe of the liver. TAE with 10 ml of Lipiodol, 50 mg of Adriamycin, and some Gelfoam was performed and leakage of Lipiodol into the peritoneal cavity from the lobulated mass was identified (Fig. 2B).

Case Reports Case 1

Discussion

A 48-year-old man was admitted to the hospital because of epigastric pain followed by diffuse abdominal pain. His blood pressure was 80/40 mmHg. Abdominal examination revealed diffuse tenderness with rebound tenderness. On laboratory findings, total bilirubin was 3.9 mg%, c~-fetoprotein (AFP) 4000 ng/ml, and carcinoembryonic antigen (CEA) 4.29 ng/ml. Paracentesis yielded bloody ascites.

The diagnosis of ruptured hepatoma is easy, if the subject has been suffering from primary carcinoma of the liver. The sudden onset of pain with shock, pallor, and hemoperitoneum should lead one to suspect rupture of the hepatoma. CT is an effective method of diagnosing rupture of the hepatoma, and is also helpful in defining the extent and age of the hematoma [5]. Hematomas are generally hyperdense in the acute stage and hypodense in the chronic stage. In our case, ruptured hepatoma was

Address offprint requests to: Pyo Nyun Kim, M.D., Department of Diagnostic Radiology, Soonchunhyang University Hospital, #23-20, Bongmyung-Dong, Chunan, Choongnam, 330-100, Korea

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Fig, 1. A,B Semilunar-shaped abnormal contrast pooling from

anterior segmental artery of the right hepatic artery is demonstrated on the late arterial phase of hepatic angiography (A) and during the injection of the mixture of Lipiodol and Adriamycin (B). C One month later, plain abdominal film reveals Lipiodol pooling in the peritoneal cavity. Fig. 2. A C T demonstrates low-density ascites and relatively increased density in ascites, suggesting recent hemorrhage. B Lipiodol angiography proves leakage of Lipiodol from the mass (arrow) and into the peritoneal cavity (arrowheads').

diagnosed by paracentesis and hyperdense hemorrhage in ascites on CT. Recently, magnetic resonance imaging (MRI) characteristics of various intraabdominal h e m a t o m a s have been described [6, 7]; H a h n et al. have noted a concentric "ring sign" in chronic h e m a t o m a s [6]. The role of M R I in diagnosing and characterizing h e m a t o m a s appears promising. T A E is useful to control bleeding and should be considered as the p r i m a r y procedure for hepatoma. Chearanai et al. was unable to demonstrate leakage of contrast on celiac angiography in 10 cases of ruptured h e p a t o m a [8]. I f active bleeding is demonstrated on hepatic angiography, cessation of bleeding should be p e r f o r m e d effectively. Most contrast media for angiography are water-soluble and diluted in the fluid. Lipiodol, however, is not diluted in the fluid, since oily c o n t r a s t medium is denser than water-soluble contrast media. L e a k a g e of Lipiodol m a y therefore be m o r e easily detected than watersoluble contrast media. In our cases, pooling or leakage of Lipiodol into the peritoneal cavity was

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demonstrated, and the ruptured hepatoma was diagnosed. 5.

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Received: August 26, 1991; accepted: October 3, 1991