Spontaneous Rupture of Hepatocellular Carcinoma: A Rare Cause of Delayed Hemorrhage in Trauma

Hepatocellular carcinoma (HCC) accounts for a portion of primary liver cancers worldwide, with hepatitis B virus (HBV) as a major risk factor. Spontaneous rupture of HCC is a rare but life-threatening event. It can be triggered by minor trauma or increased intra-abdominal pressure, necessitating a high index of suspicion in at-risk patients. A 74-year-old male with HBV presented as a level 2 trauma after a ground-level fall without obvious injuries. Initial evaluation revealed a negative extended focused assessment with sonography in trauma (eFAST). However, the patient subsequently developed hypotension unresponsive to crystalloids and worsening abdominal discomfort. Massive transfusion protocol was initiated, and a repeat FAST revealed free fluid. Emergency laparotomy identified a ruptured right hepatic mass with significant hemorrhage. Hemorrhage control was achieved via hepatic packing, the Pringle maneuver, and right hepatic artery ligation. Postoperatively, angiography with embolization was performed. On postoperative day three, a bile leak required endoscopic retrograde cholangiopancreatography (ERCP) with stent placement. His recovery was otherwise uneventful, and pathology confirmed poorly differentiated HCC. This case highlights the need for vigilance in trauma patients with risk factors for occult malignancy. The delayed hemorrhage from an undiagnosed HCC rupture emphasizes the role of serial reassessment, prompt surgical intervention, and adjunctive embolization. Trauma surgeons must recognize atypical hemorrhage presentations in at-risk patients. Timely imaging, multidisciplinary management, and early intervention are crucial to improving survival in spontaneous HCC rupture.