# Situation: A 55-year-old man with chronic hepatitis B and compensated cirrhosis is followed up at the Rural Health Unit (RHU). Later, he is found to have hepatocellular carcinoma and undergoes transarterial chemoembolization (TACE). The next day, he has a temperature of 38.2 °C, right upper quadrant pain, nausea, and fatigue. His blood pressure is 124/80 mmHg, his abdomen is soft, and he is alert. How should the nurse interpret these findings?

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> subject: Nursing Practice III — Care of Clients with Problems in Surgery, Oxygenation, Fluid and Electrolytes, Infectious, Inflammatory and Immunologic Response, Cellular Aberrations

## 문제

Situation: A 55-year-old man with chronic hepatitis B and compensated cirrhosis is followed up at the Rural Health Unit (RHU).

Later, he is found to have hepatocellular carcinoma and undergoes transarterial chemoembolization (TACE). The next day, he has a temperature of 38.2 °C, right upper quadrant pain, nausea, and fatigue. His blood pressure is 124/80 mmHg, his abdomen is soft, and he is alert. How should the nurse interpret these findings?

## 보기

1. Early rupture of the tumor into the peritoneal cavity
2. Neutropenic fever caused by the chemotherapy agent used
3. Expected post-embolization syndrome, usually self-limited **✔ 정답**
4. Hepatic encephalopathy brought on by the embolization procedure

**정답: 3**

## 해설

After TACE, tumor necrosis commonly causes post-embolization syndrome: fever, right upper quadrant pain, nausea, and fatigue that usually resolve on their own with supportive care. His stable blood pressure, soft abdomen, and alertness do not suggest bleeding or encephalopathy.

## 심화 해설

Clinical interpretation

After transarterial chemoembolization, the combination of fever, right upper quadrant pain, nausea, and fatigue in a patient with stable vital signs and a soft abdomen is best understood as post-embolization syndrome (PES). PES is a common, expected adverse event following TACE for hepatocellular carcinoma [1][2]. It reflects the inflammatory response triggered by tumor necrosis after embolization, not a procedural complication such as hemorrhage or sepsis. The patient’s blood pressure of 124/80 mmHg, soft abdomen, and alert mental status argue against tumor rupture, peritonitis, or hepatic encephalopathy.

PES is defined as fever without associated sepsis, right upper quadrant pain, and nausea and/or vomiting following TACE [2]. The fever in PES is typically low-grade and self-limited; a temperature of 38.2 °C on the first post-procedure day fits this pattern. The underlying mechanism is ischemic and inflammatory necrosis of the embolized tumor, which releases cytokines and tissue breakdown products into the circulation [1][3]. This is not a sign of bacterial infection, and it does not require antibiotics unless there is evidence of sepsis or another infectious source.

Key point! PES is a clinical syndrome, not a single symptom. The cluster of fever, pain, nausea, and fatigue after TACE should be recognized as one entity and managed supportively with antipyretics, antiemetics, and analgesia [2][3]. The nurse should monitor for resolution over the following days and watch for signs that would suggest a different diagnosis, such as worsening abdominal rigidity, hemodynamic instability, or altered mental status.

Watch out! Do not confuse PES with neutropenic fever. The chemotherapy agents used in TACE are delivered locally into the hepatic artery, and systemic myelosuppression is not the primary mechanism of fever in the immediate post-procedure period [1][3]. Neutropenic fever would require a low absolute neutrophil count and typically occurs later if systemic chemotherapy is given. In this patient, the timing and clinical picture are more consistent with PES.

| Finding | PES interpretation | Why other options are unlikely |
| --- | --- | --- |
| Fever 38.2 °C | Expected inflammatory response to tumor necrosis [1][2] | Not neutropenic fever; no evidence of neutropenia or sepsis |
| Right upper quadrant pain | Hepatic capsular distention and inflammation after embolization [2][3] | Not tumor rupture; abdomen is soft, BP stable |
| Nausea and fatigue | Common components of PES [1][2] | Not hepatic encephalopathy; patient is alert |
| BP 124/80 mmHg, soft abdomen | Hemodynamically stable, no peritoneal signs | Excludes acute bleeding or peritonitis |

The incidence of PES after TACE is substantial, and prophylactic strategies using dexamethasone, N-acetylcysteine, or their combination have been studied to reduce its severity [1][3]. However, even with prophylaxis, some degree of PES may still occur. The nurse’s role is to provide supportive care, monitor for complications, and reassure the patient that these symptoms are usually self-limited [2]. Persistent or worsening fever beyond the expected window, increasing abdominal pain with guarding, or new confusion would require prompt reassessment for alternative causes.References (research sources)

- [1]Dexamethasone and N-acetylcysteine for the prevention of post-embolization syndrome following transarterial chemoembolization in hepatocellular carcinoma: a systematic review and network meta-analysis.Meta-analysis/systematic reviewCao M, Li Z, Xue C. (2026) · DOI: 10.21037/tcr-2025-1-2815

- [2]Management of Postembolization Syndrome Following Hepatic Transarterial Chemoembolization for Primary or Metastatic Liver Cancer.Research articleBlackburn H, West S (2016) · DOI: 10.1097/NCC.0000000000000302

- [3]Efficacy of dexamethasone and N-acetylcysteine combination in preventing post-embolization syndrome after transarterial chemoembolization in hepatocellular carcinoma.Research articleSimasingha N, Tanasoontrarat W, Claimon T, Sethasine S. (2023) · DOI: 10.3748/wjg.v29.i5.890

## 임상 시나리오

Post-TACE Nursing AssessmentRecognizing expected post-embolization syndrome
After transarterial chemoembolization, the triad of fever, right upper quadrant pain, and nausea with fatigue is post-embolization syndrome, an expected inflammatory response to tumor necrosis. It is usually self-limited and resolves with supportive care.

Stable vital signs—blood pressure 124/80 mmHg, soft abdomen, and alert mental status—rule out tumor rupture, peritonitis, and hepatic encephalopathy. Fever of 38.2 °C on the first post-procedure day fits the typical low-grade pattern of PES.

CautionDo not assume infection. Antibiotics are not indicated unless there is evidence of sepsis or another infectious source. Monitor for resolution over the following days and provide antipyretics, antiemetics, and analgesia as needed.

## 핵심 개념

- **Post-embolization syndrome (PES)** — A common, self-limited inflammatory response after TACE characterized by fever, right upper quadrant pain, nausea, and fatigue due to tumor necrosis.
- **Transarterial chemoembolization (TACE)** — A locoregional therapy for hepatocellular carcinoma that delivers chemotherapy and embolic agents directly into the hepatic artery to induce tumor ischemia and necrosis.
- **Tumor necrosis** — Ischemic and inflammatory cell death of the embolized tumor, which releases cytokines and tissue breakdown products causing systemic symptoms.
- **Compensated cirrhosis** — Cirrhosis in which the liver still maintains adequate synthetic and metabolic function without major complications such as ascites, variceal bleeding, or encephalopathy.
- **Supportive care** — Management aimed at symptom relief including antipyretics, antiemetics, and analgesia without treating an underlying infection or complication.

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