Hepatic angiosarcoma (HAS) is a rare, highly aggressive vascular malignancy. HAS presents with nonspecific clinical and imaging findings, often leading to a delayed or missed diagnosis.

We describe a case of HAS in a 78-year-old woman with the chief complaints of progressive abdominal distension and anorexia. She had no history of drinking or hepatotoxic medications. Serologic testing excluded viral and autoimmune hepatitis. Contrast-enhanced computed tomography showed no discrete hepatic mass but revealed diffusely heterogeneous low-attenuation areas with patchy arterial enhancement, marked ascites, prominent collateral vessels, and architectural distortion, all of which suggestive of decompensated cirrhosis. Liver biopsy was not performed due to severe coagulopathy and thrombocytopenia. Despite comprehensive supportive care that included liver-protective agents, diuretics, albumin, and plasma transfusion, her hepatic function progressively declined, and she succumbed to liver failure approximately 180 days after presentation. Postmortem needle necropsy ultimately revealed HAS.

HAS should be considered in the differential diagnosis of rapidly progressive hepatic failure of unknown etiology, especially when imaging results show diffuse hepatic involvement without a clear mass.