Primary liver cancer is a common abdominal malignancy. Early symptoms are not obvious and progress rapidly, and most patients have reached locally advanced stage or distant metastasis by the time of diagnosis. Primary hepatocellular carcinoma mainly includes different pathological types such as hepatocellular carcinoma, intrahepatic cholangiocarcinoma and mixed hepatocellular carcinoma-intrahepatic cholangiocarcinoma. Here we focus on the symptoms, signs and common complications of hepatocellular carcinoma. 1.Symptoms Patients have no obvious clinical symptoms and signs from the beginning of the lesion until the diagnosis of subclinical hepatocellular carcinoma, and the duration of the disease is about 10 months, which is more difficult to diagnose, mostly found by serum AFP census, and a few patients can have symptoms related to chronic underlying liver disease such as epigastric stuffiness, abdominal pain, weakness and loss of appetite. Patients with intermediate or advanced hepatocellular carcinoma can show obvious clinical symptoms, which can be manifested as follows: (1) pain in the liver area. Pain in the right upper abdomen is the most common and is an important symptom of this disease. It is often intermittent or persistent vague, dull or distending pain, which increases with the development of the disease. If the tumor invades the diaphragm, the pain may spread to the right shoulder or the right back; the tumor growing backward to the right may cause pain in the right lumbar region. The cause of pain is mainly due to the tumor growth which makes the liver envelope tense. Sudden severe abdominal pain and peritoneal irritation sign may be caused by peritoneal irritation due to rupture and bleeding of subperitoneal cancer nodules. (2) Loss of appetite. Symptoms such as epigastric fullness after meals, indigestion, nausea, vomiting and diarrhea are easily ignored because of the lack of specificity. (3) Wasting and weakness. The whole body is weak, and a few patients in advanced stage may present a cachectic condition. (4) Fever. It is more common, mostly persistent and low fever, around 37.5-38℃, but it may be irregular or intermittent, persistent or chills type fever, similar to liver abscess, but no chills before fever, and antibiotic treatment is ineffective. The fever is mostly cancer fever, which is related to the absorption of tumor necrotic material; sometimes it can be caused by cholangitis due to the compression or invasion of bile ducts by the cancer, or fever due to other infections in combination with weakened resistance. (5) Symptoms of extra-hepatic metastases. For example, lung metastasis may cause cough and hemoptysis; pleural metastasis may cause chest pain and bloody pleural effusion; bone metastasis may cause bone pain or pathological fracture, etc. (6) Jaundice, bleeding tendency (gingival, nasal bleeding and subcutaneous bruises), upper gastrointestinal bleeding, hepatic encephalopathy and hepatic and renal failure are often seen in advanced stage patients. (7) Paraneoplastic syndrome is a syndrome of endocrine or metabolic disorders caused by the abnormal metabolism of liver cancer tissue itself or the multiple effects of cancer tissue on the body. The clinical manifestations are diverse and lack of specificity, including spontaneous hypoglycemia, erythrocytosis, hyperlipidemia, hypercalcemia, precocious puberty, gonadotropin secretion syndrome, cutaneous porphyria, abnormal fibrinogenemia and carcinoid syndrome, but they are relatively rare. In the early stage of hepatocellular carcinoma, most patients do not have obvious positive signs, only a few patients can be found with mild hepatomegaly, jaundice and skin pruritus on physical examination, which should be non-specific manifestations of the underlying liver disease. In intermediate to advanced hepatocellular carcinoma, jaundice, liver enlargement (hard texture, uneven surface, with or without nodules, vascular murmur) and peritoneal effusion are common. If there is a background of hepatitis or cirrhosis, liver palms, spider nevus, red nevus, abdominal wall varices and splenomegaly can be found. (1) Liver enlargement: It is often progressively enlarged, with hard texture, uneven surface, nodules of different sizes or even giant lumps, with clear edges, and often with varying degrees of tenderness and pressure pain. If the hepatocellular carcinoma protrudes to the right subcostal arch or subxiphoid process, the corresponding area can be seen to be locally full and elevated; if the carcinoma is located on the diaphragmatic surface of the liver, the diaphragm is mainly elevated in a restricted manner without enlargement of the lower edge of the liver; the carcinoma nodules located on the surface of the liver near the lower edge are most easily palpable. (2) Vascular murmur: Due to the rich and tortuous blood vessels of hepatocellular carcinoma and the sudden thinning of arteries or the compression of hepatic artery and abdominal aorta by cancer mass, about half of the patients can hear wind-like vascular murmur in the corresponding area; this sign has important diagnostic value, but it is not significant for early diagnosis. (3) Jaundice: yellow staining of the skin and sclera, often appearing in the late stage, mostly due to obstruction of the bile duct caused by the cancer or enlarged lymph nodes, or due to hepatocellular damage. (4) Portal hypertension: Patients with hepatocellular carcinoma mostly have a background of cirrhosis, so they often have portal hypertension and splenomegaly. Bloody effusion is mostly caused by cancer breaking into the abdominal cavity, and can also be caused by peritoneal metastasis; portal vein and hepatic vein cancer embolism can accelerate the growth of peritoneal effusion. Infiltration and metastasis (1) Intrahepatic metastasis: initially, most hepatocellular carcinoma is intrahepatic metastasis, which easily invades portal vein and its branches and forms tumor embolus, and then causes multiple metastases in the liver after shedding. If the tumor thrombus of the trunk branch of portal vein is obstructed, it will often cause or aggravate the existing portal hypertension. (2) Extrahepatic metastasis: ①Lung metastasis is the most common, but it can also be metastasized to the pleura, adrenal gland, kidney and bone. (2) Lymphatic metastasis, with metastasis to the hilar lymph nodes being the most common, but also to the pancreas, spleen and para-aortic lymph nodes, and occasionally to the supraclavicular lymph nodes. Occasionally, the metastasis can be planted in the peritoneum, diaphragm and chest cavity, causing bloody abdominal and pleural effusion. Common complications (1) Upper gastrointestinal bleeding: Hepatocellular carcinoma often has hepatitis and cirrhosis background accompanied by portal hypertension, and portal vein and hepatic vein cancer thrombus can further aggravate portal hypertension, so it often causes bleeding from varices in the middle and lower esophagus or fundus of stomach. If cancer cells invade the bile duct, it may cause biliary bleeding, vomiting blood and black stool. Some patients may bleed extensively due to gastrointestinal mucous membrane erosion, ulceration and coagulation dysfunction, which may lead to shock and hepatic coma. (2) Hepatic nephropathy and hepatic encephalopathy: In advanced stage of hepatocellular carcinoma, especially diffuse hepatocellular carcinoma, hepatic insufficiency or even failure can occur, causing hepatorenal syndrome, mainly manifesting as significant oliguria, decreased blood pressure, accompanied by hyponatremia, hypokalemia and azotemia, often with progressive development. Hepatic encephalopathy, i.e. hepatic coma, is often a manifestation of end-stage hepatocellular carcinoma and is often triggered by gastrointestinal bleeding, massive diuretics, electrolyte disorders and secondary infections. (3) Rupture and bleeding of hepatocellular carcinoma: It is the most urgent and serious complication of hepatocellular carcinoma. Therefore, gentle palpation is recommended during clinical examination and no forceful pressure should be applied. The rupture of cancer nodules can be confined to the subhepatic peritoneum, causing acute pain and rapid enlargement of the liver, and soft masses can be palpated locally. A small amount of bleeding can be manifested as bloody peritoneal fluid, while a large amount of bleeding can lead to shock or even rapid death. (4) Secondary infection: Patients with hepatocellular carcinoma have weakened resistance due to long-term consumption and bed-rest, especially after chemotherapy or radiotherapy when their white blood cells are reduced, they are prone to various infections, such as pneumonia, intestinal infection, fungal infection and sepsis.