HELLP syndrome with hepatic artery embolization following spontaneous hepatic rupture and hemorrhage

Case contributed by Dr Nolan Walker

Presentation

Severe abdominal pain. Pre-eclampsia. 72 hours post-partum. Derangement of LFTs and diagnosis of HELLP syndrome.

Patient Data

Age: 30 years
Gender: Female

Hepatomegaly, peri-portal edema and several possible sites of hepatic artery occlusion.

No active arterial hemorrhage or evidence of intrabdominal bleeding.

The patient developed worsening abdominal pain, peritonism and became cardiovascularly unstable. CT for ?bleeding.

Large subcapsular hematoma and a large intraabdominal bleed.

Note the irregular edge of the right lobe of the liver which suggested there was a capsular laceration. This was later confirmed at laparotomy and packing of the liver.

Hepatic artery angiogram.

No definite bleeding point was demonstrated.

However, in view of active bleeding on the CT study and the fact the patient was unstable, the decision was made to embolize the hepatic artery with gel foam.

After which, the patient was taken to the theater for drainage and packing. Then transfered to a tertiary liver unit.

This intraoperative photograph reveals that there is a laceration at the capsule of the right lobe of the liver, which correlates with the CT findings, that revealed an irregular edge of the right lobe of the liver which had developed on the second (post hemorrhage CT study).

Case Discussion

This case is interesting for a number of reasons.

The first is that we have a CT taken 5 hours before there was any intra-abdominal hemorrhage. This was performed as there was considerable abdominal pain and the possibility of hemorrhage needed to be excluded. Whilst no hemorrhage was seen, the liver was enlarged and there was the suggestion of possible hepatic artery infarcts.

This correlates well with the HELLP syndrome triad of hepatomegaly, liver hemorrhage and infarction. However, there was no active bleeding.

The subsequent CT, which was performed 5 hours later, as the patient had dropped their hemoglobin and became unstable, reveals a large subcapsular hematoma and intra-abdominal blood. Also, the liver edge is irregular in the right lobe and this suggests there has been a subcapsular laceration and hemorrhage. No definite active bleeding point is seen.

The hepatic artery embolization was performed in order to stabilize the patient. Whilst the clinical causative pathophysiology for the hemorrhage is complex: infarction within the liver causes the hemorrhage, it is generally accepted that embolization of the hepatic artery is an acceptable course of management. Even in the absence of demonstrable active bleeding 1,2.

The intraoperative photograph is very useful in confirming that there was indeed a subcapsular laceration.

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