SESSION TYPE: Critical Care Cases I
PRESENTED ON: Monday, October 22, 2012 at 01:45 PM - 03:00 PM
INTRODUCTION: Percutaneous Liver Biopsy is a generally safe and commonly used diagnostic procedure in liver disease and post transplantation patients. We report a case of massive liver necrosis resulting from an expanding subscapsular hematoma that compromised the blood supply without occlusion of portal and hepatic vessels as a complication of percutaneous liver biopsy.
CASE PRESENTATION: A 36 year old man with a history of alpha-1 anti-trypsin disease accelerated by alcoholic cirrhosis underwent orthotropic liver transplantation in 2009. He was admitted for jaundice and increased liver function tests (LFT’s). He was recently treated for acute cellular liver rejection with an increase in the immunosuppression regimen. To evaluated rising transaminases, He underwent a liver biopsy. The following day, he developed abdominal pain, tachycardia and hypotensive. Laboratory studies was positive for significant worsening LFT’s and a drop in hemoglobin. Computed tomography of the abdomen identified a large subcapsular hepatic hematoma. An urgent hepatic artery angiogram was positive for “severe spasm” but no active extravasation. The hematoma was treated conservatively. A follow up liver ultrasound showed a persistently large subscapular liver hematoma with increase portal vein peak systolic velocities but no obstruction. He had progressive jaundice and eventually died 4 weeks after the procedure from sepsis due to Clostridium difficule colits and microperforation. Autopsy revealed that the hematoma had cause significant ischemic necrosis estimated about 60% of total the liver size Hepatic vasculatures were widely patent.
DISCUSSION: We suspect that, the subcaspular hematoma was the caused massive liver necrosis in the absence of physical obstruction in liver vasculature. The mechanism is likely increase in intrahepatic pressure and development of an intrahepatic compartment syndrome. This could be exacerbated by the loss of vascular auto regulation and the loss of collateral flow in the transplanted liver. To the best of our knowledge this was previously reported once in the literature. The patient could have a different outcome if this pressure was release early.
CONCLUSIONS: Liver biopsy is generally safe with a low morbidity and mortality. Our patient liver biopsy was complicated by subscapsular hematoma and subsequent hepatic compartment syndrome. Expanding hematoma could be asymtomatic in liver transplant recipients due to the lack of innervation. Physicians have to be extra vigilant to this potentially fatal complication.
1) Van Thiel DH, Gavaler JS, Wright H, Tzakis A., Liver biopsy. Its safety and complications as seen at a liver transplant center. Transplantation. 1993;55(5):1087
2) Nicholas N. Nissen, et al., “Percutaneous Liver Biopsy after Living Donor Liver Transplantation Resulting in Fulminant Hepatic Failure: The First Reported Case of Hepatic Compartment Syndrome,” Journal of Transplantation, vol. 2010, doi:10.1155/2010/273578
DISCLOSURE: The following authors have nothing to disclose: Bashar Farjo, Brandy McKelvy
No Product/Research Disclosure InformationUniversity of Texas, Health Science Center, Houston, TX