Lower Gastrointestinal Bleeding: Liver Rams into Gut!

A 65-year-old male patient presented to the emergency department with bleeding per rectum for 1 day. He was diagnosed with hepatitis C virus-related chronic liver disease (decompensated) with hepatocellular carcinoma (HCC) (BCLC stage D) 3 months back and was on symptomatic treatment. On examination, the patient had tachycardia (pulse rate, 116/min; blood pressure, 90/50 mm Hg), pallor, and icterus. Abdominal examination revealed a large mass in the right upper quadrant. Laboratory tests were as follows: Hb, 5.8 g/dL; TLC, 20.4 × 109/L; platelets, 90 × 109/L; total bilirubin, 100.8 μmol/L; serum albumin, 22 g/L; SGOT, 120 IU/L; SGPT, 54 IU/L; INR, 2; AFP, 633 ng/mL; urea, 34.9 mmol/L; and creatinine, 136.1 μmol/L. After initial hemodynamic stabilization, a colonoscopy was performed. Colonoscopy documented a large ulcerated lesion (4 × 3 cm) near the hepatic flexure suggesting a malignant nature (Fig. 1). Multiple biopsies were taken from the ulcer margin. His previous computed tomography (CT) scan of the abdo-