S4593 Hepatocellular Carcinoma Rupture Following Colonoscopy: A Rare but Fatal Complication

Introduction: Tumor bleeding from hepatocellular carcinoma (HCC) is a well described phenomenon. Limited reporting exists regarding if endoscopy can provoke such episodes. In this case, a patient with multifocal HCC developed tumor ruptures after endoscopy resulting in death. Case Description/Methods: A 72-year-old man with a multifocal 18.5 cm HCC with metastasis to ribs, hepatitis C and prior bleeding duodenal ulcer was referred to GI clinic prior to resumption of palliative atezolizumab. GI team was asked for endoscopic bleeding risk stratification given plan to resume therapy and symptoms of rectal bleeding. Upper endoscopy identified esophagitis and colonoscopy identified multiple sub-centimeter polyps and a multi-centimeter polyp in the rectum for which endoscopic mucosal resection was conducted. In the post-anesthesia care unit (PACU), the patient had profound abdominal pain. An abdominal x-ray was obtained to evaluate for perforation and the surgical team was engaged. Imaging was negative for free air. Computed tomography abdomen and pelvis identified hemoperitoneum with active contrast extravasation from within the tumor. The patient underwent exploratory laparotomy, evacuation of hemoperitoneum, complex hepatorrhaphy and perihepatic packing. Operative findings noted tumor ruptures with visualized bleeding of left and right lobes. The patient survived the operation and was transferred to the intensive care unit in critical condition. Angiography with embolization was planned however given the patient’s instability and poor prognosis, the patient’s family elected to transition patient to comfort care measures only. Discussion: There does not appear to be report of HCC rupture following colonoscopy, however solid organ injuries, including splenic laceration have been reported. Tumor rupture is the third leading cause of death in patients with HCC. Between 5 to 15% of HCC tumors can rupture spontaneously, which should be considered prior to endoscopy as this could increase risk. A focused assessment with sonography in trauma (FAST) exam in the PACU may have expedited the patient’s diagnosis while he was awaiting computed tomography, and should be considered in patients with post procedural pain. We present this case to provide insight into this rare complication and to emphasize the importance of appropriate procedural indications.