Hepatocellular carcinoma

Last reviewed: 2 Jan 2023
Last updated: 09 Dec 2022



History and exam

Key diagnostic factors

  • presence of risk factors
  • older age
  • hepatomegaly
More key diagnostic factors

Other diagnostic factors

  • abdominal distension
  • oesophageal or gastric variceal bleeding
  • right upper quadrant abdominal pain
  • early satiety
  • weight loss
  • leg oedema
  • hepatic encephalopathy
  • cachexia
  • jaundice
  • splenomegaly
  • asterixis
  • spider naevi
  • palmar erythema
  • periumbilical collateral veins
  • fetor hepaticus
  • diarrhoea
  • paraneoplastic syndrome
  • bone pain
  • severe abdominal pain
  • obstructive jaundice
  • enlarged haemorrhoidal veins
  • vascular bruit
Other diagnostic factors

Risk factors

  • cirrhosis
  • chronic hepatitis B (HBV) infection
  • chronic hepatitis C (HCV) cirrhosis
  • chronic heavy alcohol use
  • diabetes
  • obesity
  • family history of liver cancer
  • aflatoxin
  • thorium dioxide radioactive contrast
  • haemochromatosis
  • cigarette smoking
  • alpha-1-antitrypsin deficiency
  • porphyria cutanea tarda
  • primary biliary cholangitis (PBC)
  • primary sclerosing cholangitis (PSC)
  • androgenic steroids
  • oral contraceptives
  • male sex
More risk factors

Diagnostic investigations

1st investigations to order

  • full blood count
  • basic metabolic panel
  • liver function tests
  • prothrombin time/INR
  • viral hepatitis panel
  • alpha fetoprotein (AFP)
  • ultrasound of liver
More 1st investigations to order

Investigations to consider

  • contrast CT scan of abdomen
  • contrast MRI of abdomen
  • liver biopsy
  • computed tomography scan of chest
  • bone scan
More investigations to consider

Treatment algorithm


Barcelona Clinic Liver Cancer (BCLC) stage 0-A (very early 0 or early disease A): possible surgical candidate (good liver function)

BCLC stage 0-A (very early 0 or early disease A): non-hepatic resection candidate

BCLC stage B: intermediate disease

BCLC stage C: advanced disease

BCLC stage D: end-stage disease





Qingyao Daniel Huang, MBBS, MMed (Internal Medicine), MRCP

Associate Consultant

Department of Medicine

Division of Gastroenterology & Hepatology

National University Health System



QDH declares that he has no competing interests.

Margaret Li Peng Teng, MBBS, MMed (Singapore), MRCP

Associate Consultant

Department of Medicine

Division of Gastroenterology & Hepatology

National University Hospital



MLPT declares that she has no competing interests.


Dr Qingyao Daniel Huang and Dr Margaret Li Peng Teng would like to gratefully acknowledge Dr Poh Seng Tan, Dr Badar Muneer, and Dr Smruti R. Mohanty, previous contributors to this topic.


PST has received sponsorship/honorarium from Bayer (South East Asia) Pte Ltd and Sirtex for attending conferences, delivering lectures, and participating in advisory board meetings. BM declares that he has no competing interests. SRM serves as a speaker for Bristol-Myers Squibb regarding the use of entecavir for the treatment of chronic hepatitis B.

Peer reviewers

Srikrishna Nagri, MD


Dartmouth-Hitchcock Nashua




SN declares that he has no competing interests.

Ned Snyder, MD, FACP

Professor of Medicine

Chief of Clinical Gastroenterology and Hepatology

University of Texas Medical Branch




NS declares that he has no competing interests.

  • Hepatocellular carcinoma images
  • Differentials

    • Cholangiocarcinoma
    • Hepatic adenoma
    • Haemangioma of liver
    More Differentials
  • Guidelines

    • AGA clinical practice guideline on systemic therapy for hepatocellular carcinoma
    • ACR Appropriateness Criteria: management of liver cancer
    More Guidelines
  • Calculators

    Child Pugh classification for severity of liver disease (SI units)

    More Calculators
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