A Rare Case of Hepatocellular Carcinoma Presenting as a Massive Abdominal Hematoma and Shock: A Case Report.

Hepatocellular carcinoma (HCC) has an affluent blood supply stemming from the hepatic artery. Subsequent spontaneous tumor rupture can lead to massive abdominal hematoma and shock, a rare fatal gastrointestinal incident. The diagnosis of rupture is complicated, with most patients presenting with abdominal pain and shock. Prompt correction of hypovolemic shock is the primary goal of treatment. This rare case presents a 75-year-old male who presented to the emergency department because of abrupt and increasing abdominal pain after a meal. Laboratory data revealed elevated alanine aminotransferase, aspartate aminotransferase, and alpha-fetoprotein levels. Immediate computed tomography demonstrated a defect in the right ventral abdominal wall. The patient underwent an emergency exploratory laparotomy. Despite massive intra-abdominal adhesions, the identified source of bleeding was from the left lobe of the liver at the base of the lesser sac above the pancreas. There was a maximum effort to cease bleeding and minimize blood loss. An ensuing biopsy of the liver revealed HCC. After improving, the patient received instructions to follow up on an outpatient basis. Two months after surgery, the patient endorses no complications. The success outlined in this case highlights the essence of prompt action in an emergency, which delineates the significance of surgical experience in handling unorthodox patient presentations.

Rare Metallic Allergy Reaction Presentation to Cholecystectomy Surgical Clip.

Metal allergies have been a growing concern in the general population over the past several decades. Laparoscopic cholecystectomy is the standard treatment for gallbladder diseases such as cholelithiasis and cholecystitis, during which surgical clips composed of metals such as nickel or titanium are often used to clamp the arteries and ducts. These metals are documented to produce hypersensitivity reactions. Here, we present the case of a 53-year-old male patient who successfully underwent laparoscopic cholecystectomy and two weeks later reported constant right upper quadrant pain accompanied by nausea that was exacerbated by exercise and food. After several months of severe interference with the patient's lifestyle, we removed the surgical clips after ruling out all possible organic causes of the pain. A total of six surgical clips were removed during surgery, and the patient reported a substantial resolution of symptoms post-operation. Post-cholecystectomy syndrome (PCS), allergy to the metallic surgical clips, and migration or improper clip placement during surgery were all considered possible causes for the pain. Still, the clinical presentation and laboratory studies pulled focus toward metallic surgical clip allergy as the most plausible cause for the presenting symptoms. The metallic haptens released by the surgical clips activate the innate and adaptive immune response cascades and pre-sensitize the CD8 and B cells to the metallic allergens. With reexposure, these pre-sensitized CD8 and B cells trigger a hypersensitivity reaction. Standardizing allergy tests as part of the pre-operation checklist can prove to be an inexpensive way to eliminate such post-surgical complications. Furthermore, alternatives like absorbable sutures or even different hypoallergenic metal or plastic clips can be considered viable options to replace nickel or titanium-made surgical clips during surgery.