(454) A Case of Bowel Perforation and Pancreatitis Following Alcohol Ablation of Hepatocellular Carcinoma

Introduction: Hepatocellular carcinoma (HCC) is a liver tumor frequently found in cirrhotic patients. Treatment options are divided into potentially curative surgical therapies and nonsurgical therapies. Nonsurgical liver-directed therapies encompass radiofrequency ablation (RFA), microwave ablation (MWA), and percutaneous ethanol injection (PEI). PEI is less commonly used unless RFA or MWA are unavailable but may be considered for challenging tumor locations. Major complications of PEI include bile duct dilation, intraperitoneal bleeding, liver abscess, tumor seeding, and biloma. We present a case of bowel perforation as a rare complication of PEI.

Description: A 77-year-old female with a past medical history of HCC presented to the medical intensive care unit (MICU) for severe abdominal pain. The patient had undergone PEI of HCC 3 days prior to presentation. She had a GCS of 13 on arrival, a temperature of 96 F, a heart rate of 93 beats/minute, a respiratory rate of 24/minute, blood pressure of 113/59 mm Hg, and SpO2 97% on 4 liters of the nasal cannula. Her exam was significant for abdominal guarding. Her labs were significant for lactic acidosis (7.7mmol/L), hyponatremia (128mmol/L), Lipase (1000U/L), and markedly abnormal liver function tests. CAT Scan of the abdomen and pelvis showed pneumoperitoneum. She progressively worsened, requiring emergent endotracheal intubation and vasopressors for septic shock. Surgery and Interventional Radiology evaluated the patient and concluded that the trauma from PEI resulted in pneumoperitoneum and necrotizing pancreatitis as well as gastric perforation, splenic infarcts, and likely celiac trunk thrombosis, all considered non-survivable and not a surgical candidate. The patient was in profound shock and severe metabolic acidosis despite maximum ICU supportive care. Given the overall poor prognosis, the family proceeded with comfort care measures. Patient was terminally extubated and expired.

Discussion: This case underscores a rare and life-threatening complication following PEI in a patient with HCC. This scenario necessitates considering bowel perforation as a potential complication, which can lead to sepsis, multi-organ failure, and death. Early consideration and intervention in such cases might significantly affect patient outcomes.