A Case of Ruptured Hepatocellular Carcinoma As the Initial Presentation of Undiagnosed Hepatitis B-related Cirrhosis in a Young Adult

Spontaneous rupture of hepatocellular carcinoma (HCC) is a life-threatening oncologic emergency and can be the first manifestation of untreated chronic liver disease. We report the case of a 42-year-old male with no known medical history who presented with severe right upper quadrant and referred shoulder pain. Examination revealed ascites and cachexia. Laboratory tests showed bicytopenia, impaired liver synthetic function, and chronic hepatitis B virus (HBV) infection, despite a normal alpha-fetoprotein (AFP) level. Imaging demonstrated a cirrhotic liver with a large exophytic LI-RADS 5 mass in segment VIII and clear extracapsular rupture. After a multidisciplinary diagnosis of ruptured AFP-negative HCC on a background of undiagnosed Child-Pugh B (score 6) cirrhosis, the patient was stabilized. Antiviral therapy (entecavir) was initiated, and transarterial chemoembolization (TACE) was planned. At discharge, the patient was hemodynamically stable and scheduled for outpatient TACE. This case highlights that ruptured HCC can be a sentinel event in occult cirrhosis, even in younger patients. It underscores the importance of considering HCC in acute abdomen, the limitations of AFP as a sole screening marker (with up to 30% of HCCs being AFP-negative), and the value of a multidisciplinary approach.