Management of Ruptured Hepatic Tumors

  • Jillian Piaggione
  • Richard Smith


Ruptured hepatic tumors are a rare but potentially fatal clinical presentation. The most commonly ruptured benign and malignant hepatic tumors are hepatic adenoma and hepatocellular carcinoma, respectively. Acute management focuses on control of bleeding usually through transcatheter embolization. Definitive management is based on the patient’s clinical condition and tissue type.


Spontaneous tumor rupture Hepatocellular carcinoma Hepatic adenoma hemoperitoneum 


  1. 1.
    Battula N, Tsapralis D, Takhar A, Coldham C, Mayer D, Isaac J, Bramhall SR. Aetio-pathogenesis and the management of spontaneous liver bleeding in the West: a 16-year single-centre experience. HPB (Oxford). 2012;14(6):382–9.Google Scholar
  2. 2.
    Liu CL, Fan ST, Lo CM, et al. Management of spontaneous rupture of hepatocellular carcinoma: single center experience. J Clin Oncol. 2001;19:3725–2730.PubMedGoogle Scholar
  3. 3.
    Sicklick JK, D’Angelica M, Fong Y. The liver. In: Townsend CM, Beauchamp RD, Evers BM, Mattox KL, editors. Sabiston textbook of surgery: the biological basis of modern surgical practice. 19th ed; 2012. p. 1411–75.Google Scholar
  4. 4.
    Choi BY, Nguyen MH. The diagnosis and management of benign hepatic tumors. J Clin Gastroenterol. 2005;39:401–12.PubMedGoogle Scholar
  5. 5.
    Beatty J, Mitchell J, Holsten S, Ferdinand C. Traumatic rupture of a previously undiagnosed Giant hepatic hemangioma. Ann Surg. 2013;79:e314–5.Google Scholar
  6. 6.
    Ribeiro MA Jr, Papaiordanou F, JM G, et al. Spontaneous rupture of hepatic hemangiomas: a review of the literature. World J Hepatol. 2010;2:428–33.PubMedGoogle Scholar
  7. 7.
    Güngör T, Aytan H, Tapisiz OL, Zergeroĝlu S. An unusual case of incidental rupture of liver hemangioma during labor. Chin Med J (Engl). 2004;117:311–3.Google Scholar
  8. 8.
    Costa SRP, Speranzini MB, Horta SH, Miotto MJ, Myake A, Henriques AC. Surgical treatment of painful hepatic hemangioma. Einstein. 2009;7:88–90.Google Scholar
  9. 9.
    Vokaer B, Kothonidis K, Delatte P, De Cooman S, Pector JC, Liberale G. Should ruptured liver haemangioma be treated by surgery or by conservative means? A case report. Acta Chir Belg. 2008;108:761–4.PubMedGoogle Scholar
  10. 10.
    Aiura K, Ohshima R, Matsumoto K, Ishii S, Arisawa Y, Nakagawa M, Nakagawa M, Noga K. Spontaneous rupture of liver hemangioma: risk factors for rupture. J Hepato-Biliary-Pancreat Surg. 1996;3:308–12.Google Scholar
  11. 11.
    Corigliano N, Mercantini P, Amodio PM, et al. Hemoperitoneum from a spontaneous rupture of a giant hemangioma of the liver: report of a case. Surg Today. 2003;33:459–63.PubMedGoogle Scholar
  12. 12.
    Jain V, Ramachandran V, Garg R, Pal S, Gamanagatti SR, Srivastava DN. Spontaneous rupture of a giant hepatic hemangioma- sequential management with transcatheter arterial embolization and resection. Saudi J Gastroenterol. 2010;16:116–9.PubMedPubMedCentralGoogle Scholar
  13. 13.
    Yamamoto T, Kawarada Y, Yano T, Noguchi T, Mizumoto R. Spontaneous rupture of hemangioma of the liver: treatment with transcatheter hepatic arterial embolization. Am J Gastroenterol. 1991;86:1645–9.PubMedGoogle Scholar
  14. 14.
    Rooks JB, Ory HW, Ishak KG, Strauss LT, Greenspan JR, Hill AP, et al. Epidemiology of hepatocellular adenoma. The role of oral contraceptive use. JAMA. 1979;242:644–8.PubMedGoogle Scholar
  15. 15.
    Klompenhouwer AJ, de Man RA, Thomeer MGJ, Ijzermans JNM. Management and outcome of hepatocellular adenoma with massive bleeding at presentation. World J Gastroenterol. 2017;23(25):4579–86.PubMedPubMedCentralGoogle Scholar
  16. 16.
    Stoot JH, Coelen RJ, De Jong MC, Dejong CH. Malignant transformation of hepatocellular adenomas into hepatocellular carcinomas: a systematic review including more than 1600 adenoma cases. HPB (Oxford). 2010;12:509–22.Google Scholar
  17. 17.
    van Aalten SM, de Man RA, IJzermans JN, Terkivatan T. Systematic review of hemorrhage and rupture of hepatocellular adenomas. Br J Surg. 2012;99:911–6.PubMedGoogle Scholar
  18. 18.
    Bieze M, Phoa SS, Verheij J, van Lienden KP, van Gulik TM. Risk factors for bleeding in hepatocellular adenoma. Br J Surg. 2014;101:847–55.PubMedGoogle Scholar
  19. 19.
    Stoot JH, van der Linden E, Terpstra OT, Schaapherder AF. Lifesaving therapy for hemorrhaging liver adenomas using selective arterial embolization. Br J Surg. 2007;94:1249–53.PubMedGoogle Scholar
  20. 20.
    Terkivatan T, de Wilt JH, de Man RA, van Rijn RR, Tilanus HW, IJzermans JN. Treatment of ruptured hepatocellular adenoma. Br J Surg. 2001;88:207–9.PubMedGoogle Scholar
  21. 21.
    van Aalten SM, Thomeer MG, Terkivatan T, Dwarkasing RS, Verheij J, de Man RA, Ijzermans JN. Hepatocellular adenomas: correlation of MR imaging findings with pathologic subtype classification. Radiology. 2011;261:172–81.PubMedGoogle Scholar
  22. 22.
    Ronot M, Bahrami S, Calderaro J, Valla DC, Bedossa P, Belghiti J, Vilgrain V, Paradis V. Hepatocellular adenomas: accuracy of magnetic resonance imaging and liver biopsy in subtype classification. Hepatology. 2011;53:1182–91.PubMedGoogle Scholar
  23. 23.
    Laumonier H, Bioulac-Sage P, Laurent C, Zucman-Rossi J, Balabaud C, Trillaud H. Hepatocellular adenomas: magnetic resonance imaging features as a function of molecular pathological classification. Hepatology. 2008;48:808–18.PubMedGoogle Scholar
  24. 24.
    Bioulac-Sage P, Laumonier H, Couchy G, Le Bail B, Sa Cunha A, Rullier A, et al. Hepatocellular adenoma management and phenotypic classification: the Bordeaux experience. Hepatology. 2009;50:481–9.PubMedGoogle Scholar
  25. 25.
    van Aalten SM, Verheij J, Terkivatan T, Dwarkasing RS, de Man RA, Ijzermans JN. Validation of a liver adenoma classification system in a tertiary referral centre: implications for clinical practice. J Hepatol. 2011;55(1):120–5.PubMedGoogle Scholar
  26. 26.
    Ault GT, Wren SM, Ralls PW, Reynolds TB, Stain SC. Selective management of hepatic adenomas. Am Surg. 1996;62:825–9.PubMedGoogle Scholar
  27. 27.
    Edmondson HA, Reynolds TB, Henderson B, Benton B. Regression of liver cell adenomas associated with oral contraceptives. Ann Intern Med. 1977;86:180–2.PubMedGoogle Scholar
  28. 28.
    Ramseur WL, Cooper MR. Asymptomatic liver cell adenomas. Another case of resolution after discontinuation of oral contraceptive use. JAMA. 1978;239:1647–8.PubMedGoogle Scholar
  29. 29.
    Steinbrecher UP, Lisbona R, Huang SN, Mishkin S. Complete regression of hepatocellular adenoma after withdrawal of oral contraceptives. Dig Dis Sci. 1981;26:1045–50.PubMedGoogle Scholar
  30. 30.
    Huurman V, Schaapherder A. Management of ruptured hepatic adenoma. Dig Surg. 2010;27:56–60.PubMedGoogle Scholar
  31. 31.
    Thomeer M, Broker M, Verheij J, Doukas M, Terkivata T, Bijdevaate D, De Man R, Moelker A, IJzermans J. Hepatocellular adenoma: when and how to treat? Update of current evidence. Ther Adv Gastroenterol. 2016;9:898–912.Google Scholar
  32. 32.
    Deneve JL, Pawlik TM, Cunningham S, Clary B, Reddy S, Scoggins CR, Martin RC, D’Angelica M, Staley CA, Choti MA, Jarnagin WR, Schulick RD, Kooby DA. Liver cell adenoma: a multicenter analysis of risk factors for rupture and malignancy. Ann Surg Oncol. 2009;16:640–8.PubMedGoogle Scholar
  33. 33.
    Xu HS, Yan JB. Conservative management of spontaneous ruptured hepatocellular carcinoma. Am Surg. 1994;60:629–33.PubMedGoogle Scholar
  34. 34.
    Shortell CK, Schwartz SI. Hepatic adenoma and focal nodular hyperplasia. Surg Gynecol Obstet. 1991;173:426–31.PubMedGoogle Scholar
  35. 35.
    Karkar A, Tang L, Kashikar N, Gonen M, Solomon S, Dematteo R, et al. Management of hepatocellular adenoma: comparison of resection, embolization and observation. HPB (Oxford). 2013;15:235–43.Google Scholar
  36. 36.
    Parizel PM, Makkat S, Van Miert E, Van Goethem JW, van den Hauwe L, De Schepper AM. Intracranial hemorrhage: principles of CT and MRI interpretation. Eur Radiol. 2001;11:1770–83.PubMedGoogle Scholar
  37. 37.
    Toso C, Majno P, Andres A, Rubbia-Brandt L, Berney T, Buhler L, Morel P, Mentha G. Management of hepatocellular adenoma: solitary-uncomplicated, multiple and ruptured tumors. World J Gastroenterol. 2005;11:5691–5.PubMedPubMedCentralGoogle Scholar
  38. 38.
    Okazaki M, Higashihara H, Koganemaru F, et al. Intraperitoneal hemorrhage from hepatocellular carcinoma: emergency chemoembolization or embolization. Radiology. 1991;180:647–51.PubMedGoogle Scholar
  39. 39.
    Yang T, Sun YF, Zhang J, Lau WY, Lai EC, Lu JH, Shen F, Wu MC. Partial hepatectomy for ruptured hepatocellular carcinoma. Br J Surg. 2013;100:1071–9.PubMedGoogle Scholar
  40. 40.
    Deodhar A, Brody L, Covey A, Brown K, Getrajdman G. Bland embolization in the treatment of hepatic adenomas: preliminary experience. J Vasc Interv Radiol. 2011;22:795–9.PubMedGoogle Scholar
  41. 41.
    Erdogan D, van Delden O, Busch O, Gouma D, van Gulik T. Selective transcatheter arterial embolization for treatment of bleeding complications or reduction of tumor mass of hepatocellular ad. Cardiovasc Intervent Radiol. 2007;30:1252–8.PubMedGoogle Scholar
  42. 42.
    Cobey FC, Salem RR. A review of liver masses in pregnancy and a proposed algorithm for their diagnosis and management. Am J Surg. 2004;187:181–91.PubMedGoogle Scholar
  43. 43.
    Noels JE, van Aalten SM, van der Windt DJ, Kok N, de Man RA, Terkivatan T, IJzermans J. Management of Hepatocellular adenoma during pregnancy. J Hepatol. 2011;54:553–8.PubMedGoogle Scholar
  44. 44.
    Parangi S, levine D, Henry A, Isakovich N, Pories S. Surgical gastrointestinal disorders during pregnancy. Am J Surg. 2007;193:223–32.PubMedGoogle Scholar
  45. 45.
    Kinoshita M, Takemura S, Tanaka S, Hamano G, Ito T, Aota T, Koda M, Ohsawa M, Kubo S. Ruptured focal nodular hyperplasia observed during follow-up: a case report. Surg Case Rep. 2017;3:44.PubMedPubMedCentralGoogle Scholar
  46. 46.
    Becker YT, Raiford DS, Webb L, Wright JK, Chapman WC, Pinson CW. Rupture and hemorrhage of hepatic focal nodular hyperplasia. Am Surg. 1995;61:210–4. [PubMed]PubMedGoogle Scholar
  47. 47.
    Mays ET, Christopherson WM, Barrows GH. Focal nodular hyperplasia of the liver. Possible relationship to oral contraceptives. Am J Clin Pathol. 1974;61:735–46.PubMedGoogle Scholar
  48. 48.
    Hardwigsen J, Pons J, Veit V, Garcia S, Le Treut YP. A life-threatening complication of focal nodular hyperplasia. J Hepatol. 2001;35:310–2.PubMedGoogle Scholar
  49. 49.
    Bathe OF, Mies C, Franceschi D, Casillas J, Livingstone AS. Massive hemorrhage and infarction complicating focal nodular hyperplasia of the liver. HPB. 2003;5:123–6.PubMedPubMedCentralGoogle Scholar
  50. 50.
    Chang SK, Chung YF, Thng CH, Loo HW. Focal nodular hyperplasia presenting as acute abdomen. Singap Med J. 2005;46:90–2.Google Scholar
  51. 51.
    Rahili A, Cai J, Trastour C, Juwid A, Benchimol D, Zheng M, et al. Spontaneous rupture and hemorrhage of hepatic focal nodular hyperplasia in lobus caudatus. J Hepato-Biliary-Pancreat Surg. 2005;12:138–42. Scholar
  52. 52.
    Demarco MP, Shen P, Bradley RF, Levine EA. Intraperitoneal hemorrhage in a patient with hepatic focal nodular hyperplasia. Am Surg. 2006;72:555–9.PubMedGoogle Scholar
  53. 53.
    Li T, Qin LX, Ji Y, Sun HC, Ye QH, Wang L, et al. Atypical hepatic focal nodular hyperplasia presenting as acute abdomen and misdiagnosed as hepatocellular carcinoma. Hepatol Res. 2007;37:1100–5.PubMedGoogle Scholar
  54. 54.
    Yajima D, Kondo F, Nakatani Y, Saitoh H, Hayakawa M, Sato Y, et al. A fatal case of subcapsular liver hemorrhage in late pregnancy: a review of hemorrhages caused by hepatocellular hyperplastic nodules. J Forensic Sci. 2013;58:S253–7.PubMedGoogle Scholar
  55. 55.
    Vergara V, Muratore A, Bouzari H, Polastri R, Ferrero A, Galatola G, Capussotti L. Spontaneous rupture of hepatocellular carcinoma: surgical resection and long-term survival. Eur J Surg Oncol. 2000;26:770–2.PubMedGoogle Scholar
  56. 56.
    Chen CY, Lin XZ, Shin JS, et al. Spontaneous rupture of hepatocellular carcinoma. A review of 141 Taiwanese cases and comparison with nonrupture cases. J Clin Gastroenterol. 1995;21:238–42.PubMedGoogle Scholar
  57. 57.
    Ong GB, Taw JL. Spontaneous rupture of hepatocellular carcinoma. BMJ. 1972;4:146–9.PubMedGoogle Scholar
  58. 58.
    Scwartz L, Bubenheim M, Zemour J, Herrero A, Muscari F, Ayav A, Riboud R, et al. Bleeding recurrence and mortality following interventional management of spontaneous HCC rupture: results of a multicenter European study. World J Surg. 2018;42:225–3.Google Scholar
  59. 59.
    Zhu Q, Jing L, Yan J, Huang L, Wu M, Yan Y. Predictors and clinical outcomes for spontaneous rupture of hepatocellular carcinoma. World J Gastroenterol. 2012;18:7302–7.PubMedPubMedCentralGoogle Scholar
  60. 60.
    Lai E, Wu K, Choi T, Fan S, Wong J. Spontaneous ruptured hepatocellular carcinoma: an appraisal of surgical treatment. Ann Surg. 1989;210:24–8.PubMedPubMedCentralGoogle Scholar
  61. 61.
    Kung C, Liu B, Ng S, Lee T, Cheng Y, Chen M, Ko S. Transcatheter arterial embolization in the emergency department for hemodynamic instability due to ruptured hepatocellular carcinoma: analysis of 167 cases. Am J Roentgenol. 2008;19:W231–9.Google Scholar
  62. 62.
    Aoki T, Kokudo N, Matsuyama Y, et al. Prognostic impact of spontaneous tumor rupture in patients with hepatocellular carcinoma: an analysis of 1160 cases from a nationwide survey. Ann Surg. 2014;259:532–42.PubMedGoogle Scholar
  63. 63.
    Moris D, Chakedis J, Sun S, Spolverato G, Tsilimigras D, Ntanasis-Stathopoulos I, Spartalis E, Pawlik T. Management, outcomes, and prognostic factors of ruptured hepatocellular carcinoma: a systematic review. J Surg Oncol. 2018;117:341–53.PubMedGoogle Scholar
  64. 64.
    Chan AC, Dai JW, Chok KS, Cheung TT, Lo CM. Prognostic influence of spontaneous tumor rupture on hepatocellular carcinoma after interval hepatectomy. Surgery. 2016;159:409–17.PubMedGoogle Scholar
  65. 65.
    Lai ECH, Lau WY. Spontaneous rupture of hepatocellular carcinoma: a systematic review. Arch Surg. 2006;141:191–8.PubMedGoogle Scholar
  66. 66.
    Li J, Huang L, Liu C, Cai J, Yan J, Xu F, Wu M, Yan Y. Risk factors and surgical outcomes for spontaneous rupture of BCLC stages A and B hepatocellular carcinoma: a case control study. World J Gastroenterol. 2014;20:9121–7.PubMedPubMedCentralGoogle Scholar
  67. 67.
    Zhu LX, Wang GS, Fan ST. Spontaneous rupture of hepatocellular carcinoma. Br J Surg. 1996;83:602–7.PubMedGoogle Scholar
  68. 68.
    Zhu LX, Liu Y, Fan ST. Ultrastructural study of the vascular endothelium of patients with spontaneous rupture of hepatocellular carcinoma. Asian J Surg. 2002;25:157–62.PubMedGoogle Scholar
  69. 69.
    Zhong F, Cheng XS, He K, et al. Treatment outcomes of spontaneous rupture of hepatocellular carcinoma with hemorrhagic shock: a multicenter study. Springerplus. 2016;5:1101.PubMedPubMedCentralGoogle Scholar
  70. 70.
    Chearanai O, Plengvanit U, Asavanich C, Damrongsak D, Sindhvananda K, Boonyapisit S. Spontaneous rupture of primary hepatoma: report of 63 cases with particular reference to the pathogenesis and rationale of treatment by hepatic artery ligation. Cancer. 1983;51:1532–6.PubMedGoogle Scholar
  71. 71.
    Balasegaram M. Spontaneous intraperitoneal rupture of primary liver-cell carcinoma. Aust N Z J Surg. 1968;37:332–7.PubMedGoogle Scholar
  72. 72.
    Saifi J, Fortune JB, Graca L, Shah DM. Benefits of intra-abdominal pack placement for the management of nonmechanical hemorrhage. Arch Surg. 1990;125:119–22.PubMedGoogle Scholar
  73. 73.
    Abikhaled JA, Granchi TS, Wall MJ, Hirshberg A, Mattox KL. Prolonged abdominal packing for trauma is associated with increased morbidity and mortality. Am Surg. 1997;63:1109–12.PubMedGoogle Scholar
  74. 74.
    Caruso DM, Battistella FD, Owings JT, Lee SL, Samaco RC. Perihepatic packing of major liver injuries: complications and mortality. Arch Surg. 1999;134:958–62.PubMedGoogle Scholar
  75. 75.
    Leung KL, Lau WY, Lai PBS, Yiu RYC, Meng WCS, Leow CK. Spontaneous rupture of hepatocellular carcinoma. Arch Surg. 1999;134:1103–7.PubMedGoogle Scholar
  76. 76.
    Hai L, Yong-Hong P, Yong F, Ren-Feng L. One-stage liver resection for spontaneous rupture of hepatocellular carcinoma. World J Surg. 2005;29:1316–8.PubMedGoogle Scholar
  77. 77.
    Ngan H, Tso WK, Lai CL, Fan ST. The role of hepatic arterial embolization in the treatment of spontaneous rupture of hepatocellular carcinoma. Clin Radiol. 1998;53:338–41.PubMedGoogle Scholar
  78. 78.
    Hirai K, Kawazoe Y, Yamashita K, et al. Transcatheter arterial embolization for spontaneous rupture of hepatocellular carcinoma. Am J Gastroenterol. 1986;81:275–9.PubMedGoogle Scholar
  79. 79.
    Hsieh JS, Huang CJ, Huang YS, Sheen PC, Huang TJ. Intraperitoneal hemorrhage due to spontaneous rupture of hepatocellular carcinoma: treatment by hepatic artery embolization. AJR Am J Roentgenol. 1987;149:715–7.PubMedGoogle Scholar
  80. 80.
    Leung CS, Tang CN, Fung KH, Li MKW. A retrospective review of transcatheter hepatic arterial embolization for ruptured hepatocellular carcinoma. J R Coll Surg Edinb. 2002;47:685–8.PubMedGoogle Scholar
  81. 81.
    Sato Y, Fujiwara K, Furui S, et al. Benefit of transcatheter arterial embolization for ruptured hepatocellular carcinoma complicating liver cirrhosis. Gastroenterology. 1985;89:157–9.PubMedGoogle Scholar
  82. 82.
    Corr P, Chan M, Lau WY, Metreweli C. The role of hepatic arterial embolization in the management of ruptured hepatocellular carcinoma. Clin Radiol. 1993;48:163–5.PubMedGoogle Scholar
  83. 83.
    Yeh C, Lee W, Jeng L, Chen M, Yu M. Spontaneous tumor rupture and prognosis in patients hepatocellular carcinoma. Br J Surg. 2002;89:1125–9.PubMedGoogle Scholar
  84. 84.
    Tanaka S, Kaibori M, Ueno M, et al. Surgical outcomes for the ruptured hepatocellular carcinoma: multicenter analysis with a case-controlled study. J Gastrointest Surg. 2016;20:2021–34.PubMedGoogle Scholar
  85. 85.
    American Joint Committee on Cancer. Cancer staging manual. New York: Springer; 2009.Google Scholar

Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  • Jillian Piaggione
    • 1
  • Richard Smith
    • 2
  1. 1.Department of SurgeryTripler Medical CenterHonoluluUSA
  2. 2.Department of SurgeryUniversity of MissouriColumbiaUSA

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