Hepatic hemorrhage

Case contributed by Dr Lawrence Josey

Presentation

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 utilized at the time of the biopsy. Ultrasound identified free fluid within the abdomen, patient immediately transfered to CT for multiphase aquisition.

Patient Data

Age: 50 years
Gender: Female
ct

Active contrast blush can be seen within segment 5 of the liver extending to the anterior surface of the right lobe of the liver and into the surrounding free fluid.

Extravasated contrast dissipates. Note additional changes consistent with portal hypertension. 

dsa

Super selective 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. Embolization was not performed due to the already compromised liver function. The bleeding stopped spontaneously during the attempts at catheterization of the smaller vessels.

Case Discussion

Ongoing life-threatening liver bleeding (hemoperitoneum) 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 embolization of the site of hemorrhage 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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