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Hepatic haemorrhage

Case contributed by: Dr Lawrence Josey

Presentation:

Middel aged female admitted with decompensated chronic liver disease. Medical Emergency Response Team called due to hypotension. Ultrasound guided biopsy performed by an experienced interventional radiologist 2 days earlier. Gel Foam Plugs utilised at the time of the biopsy.

Patient Data:

Age: 49
Gender: Female
Race: Caucasian
From the case: Hepatic haemorrhage

Ultrasound identified free fluid within the abdomen, patient immediately transfered to CT for multiphase aquisition.

Modality: CT

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  • Active contrast blush can be seen within segment 5 of the liver extending to the anterior surface of the right lobe of liver and into the surrounding free fluid.
Active contrast blush can be seen within segment 5 of the liver extending to the anterior surface of the right lobe of liver and into the surrounding free fluid.
From the case: Hepatic haemorrhage
Modality: DSA (angiography)
  • Superselective <a href="/articles/angiography" title="angiography">angiograms</a> in liver segmental arteries identified that the hepatic bleeding site is in a "watershed" area, between two of the segmental artery territories. This means that both territories could require treatment for successful control. <a href="/articles/post-embolisation-syndrome" title="Post embolisation syndrome (PES)">Embolisation </a>was not performed due to the already compromised liver function. The bleeding stopped spontaneously during the attempts at catheterisation of the smaller vessels.

Hepatic artery proper

Superselective angiograms in liver segmental arteries identified that the hepatic bleeding site is in a "watershed" area, between two of the segmental artery territories. This means that both territories could require treatment for successful control. Embolisation was not performed due to the already compromised liver function. The bleeding stopped spontaneously during the attempts at catheterisation of the smaller vessels.

Case Discussion:

Ongoing life-threatening liver bleeding(haemoperitoneum) post-liver biopsy in a patient with end stage cirrhosis and advanced liver failure. Bilirubin >400.

INR rapidly increased after the liver biopsy  indicating grossly impaired synthetic function. In the 12 hours prior to the attempted embolisation of the site of haemorrhage the patient was anuric with a systolic blood pressure having dropped to 60mmHg and requiring ICU support. Large volume transfusions of products were given to to correct the coagulopathy - INR reduced from 6.6 to 1.8. Post 5 unit blood transfusion - Hb had not improved.

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