Hepatocellular Carcinoma

A 35-year-old Nigerian man presented to the emergency department with a distended, tender abdomen; fever; and weight loss. His abdomen had grown increasingly large during the past several months as his appetite diminished. The patient reported no allergies, took no medication, and denied tobacco, alcohol, and illicit drug use. His only significant medical history was jaundice during adolescence.

The patient appeared cachectic, with tense ascites and atrophy of the upper and lower extremities. He had scleral icterus and small testicles. His temperature was 38.4°C (101.2°F). Results of liver function tests-including bilirubin and alkaline phosphatase levels-were elevated; hematocrit was 28%. Abdominal paracentesis revealed an exudate. The bandage on the abdomen was placed after the paracentesis to prevent ascites fluid leakage from the peritoneum. Serological tests showed the presence of hepatitis B antigen; bridging necrosis and fibrosis detected on liver biopsy confirmed the diagnosis of chronic hepatitis B. Abdominal ultrasonography revealed massive ascites and hepatomegaly.

After several days in the hospital, severe abdominal pain and fever developed. A presumed diagnosis of peritonitis was made based on an elevated white blood cell count (1000/µL) in the ascites fluid.

Intravenous cefotaxime was initiated. The patient's health continued to deteriorate; he died after 1 week in the hospital.

Gopi Rana-Mukkavilli, MD of New York City writes that postmortem laboratory data revealed an elevated alpha-fetoprotein level. Autopsy showed fulminant sepsis and hepatoma.

Hepatocellular carcinoma is prevalent in parts of Africa, Southeast Asia, and Japan. The disease predominates in men and usually arises in a cirrhotic liver. It occurs most often in patients with cirrhosis associated with hepatitis B or C.¹

Abdominal pain, weight loss, and ascites are common presenting features of hepatocellular carcinoma. The portal and hepatic veins may be affected by the malignancy, which usually metastasizes to regional lymph nodes and the lungs. Elevation of the tumor marker alpha-fetoprotein is a sensitive indicator of liver cancer.

The median survival time from diagnosis is about 6 months. Liver transplantation is the only treatment available for patients with hepatocellular carcinoma.

REFERENCE:1. Fauci AS, Braunwald E, Isselbacher KJ, et al, eds. Harrison's Principles of Internal Medicine. 14th ed. New York: McGraw-Hill; 1998:319-320.