Usefulness of contrast-enhanced ultrasonography in the diagnosis of ruptured hepatocellular carcinoma
The patient was a 61-year-old male. He had no relevant medical or family history, but he was a heavy drinker who consumed >2 L of beer every day. He visited a nearby hospital for a chief complaint of general malaise and was diagnosed with multiple HCCs caused by alcohol-related cirrhosis. Approximately 1 month after the first visit, he was admitted to our hospital for rapid development of abdominal fullness. Physical findings at admission showed blood pressure 148/98 mmHg, pulse rate 64 bpm, ascites retention, and a palpable fist-sized tumor in the epigastric region. Blood tests upon admission showed Hb 10.4 g/dl (normal 14.0–17.0 g/dl), AST 55 U/l (normal 12–35 U/l), ALT 35 U/l (normal 6–31 U/l),γ-GTP 283 U/l (normal 9–58 U/l), T-Bil 4.9 mg/dl (normal 0.1–1.0 mg/dl) and PT % 68 % (normal ≥70 %), suggesting mild anemia and increased hepatobiliary enzymes. Hepatic function was evaluated as C (10 points) in the Child–Pugh classification. Tumor markers were high, as shown by the levels of AFP and PIVKA II of 27.4 ng/ml (normal 0.0–15.0 ng/ml) and 567 mAU/ml (normal <40 mAU/ml), respectively. HBV and HCV were negative and renal function was normal. Hemorrhagic ascites was found in abdominal paracentesis and the case was diagnosed as ruptured HCC.\nAbdominal CECT showed a large HCC with a maximum diameter of 15 cm in S7/8 of the liver and multiple HCCs in both lobes (Fig. ). The attenuation value of the ascites was as high as 30 Hounsfield units, but no clear extravasation was found in the arterial and equilibrium phase, and thus the bleeding site could not be identified. Abdominal ultrasonography also showed multiple tumors in both lobes and ascites with high echo density (Fig. a). However, even with these data the bleeding site was unclear, and CEUS was performed for the large HCC in S7/8 as the region of interest. The ultrasound equipment used in this examination was SSA-790A (Toshiba Medical Systems, Tokyo, Japan) with a convex probe (PVT-375BT, 3.75-MHz center frequency). The imaging mode used was wideband harmonic imaging (pulse subtraction) with transmission/reception frequencies of 1.8 and 3.5 MHz, respectively. The mechanical index for acoustic output was set to 0.2; the dynamic range was set to 60–65 dB. A intravenous bolus injection of Sonazoid (0.5 ml) was administered via a left cubital venous line followed by 10 ml normal saline flush. Observation in the arterial phase showed no clear leakage of contrast agent from this tumor, but punctate high-intensity echoes of Sonazoid microbubbles were observed in ascites. In particular, extremely high-intensity echoes of Sonazoid microbubbles were present in ascites surrounding the tumor, close to the S5 gallbladder bed. The tumor was imaged again using the re-injection method [] with Sonazoid in the post-vascular phase and leakage of the contrast agent from the tumor into the abdominal cavity was observed, indicating that this was the site of bleeding (Fig. b).\nAbdominal angiography was urgently performed. Imaging of the celiac artery and hepatic artery showed no clear extravasation. However, since the tumor on the gallbladder bed was suspected as the bleeding site based on CEUS, selective cannulation of the cystic artery was performed (Fig. a). The artery was imaged using carbon dioxide (CO2), which is a highly sensitive method for evaluation of blood flow []. Leakage of CO2 out of the vessel was apparent, confirming that the bleeding site was the tumor in S5, which was fed by the cystic artery (Fig. b). TAE was conducted using a gelatin sponge (Gelpart; Astellas Pharma, Tokyo, Japan) with a particle size of 1 mm, and the clinical course after TAE was favorable with arrest of bleeding.