Spontaneous hepatic rupture in pregnancy

Hepatic rupture as a late complication of toxemic pregnancy is a rare yet lethal condition requiring rapid recognition and surgical management. The clinical triad of toxemia, right upper quadrant pain, and sudden hypotension is the diagnostic hallmark of presentation. Most patients present near the time of delivery and are found to have subcapsular hematomas of the right hepatic lobe with free rupture into the peritoneal cavity and resultant exsanguinating hemorrhage. The association of toxemia and disseminated intravascular coagulation with secondary microembolic damage to the liver and other organs has been discussed. Basic surgical principles in the management of hepatic subcapsular hematomas, and the prolonged postoperative course and frequent complications in these patients have been stressed.     

Hemorrhagic hepatic lesions in toxemia of pregnancy

One case of hepatic hemorrhage during toxemia of pregnancy is reported. This complication occurs in the last trimester of the pregnancy or immediately after labor. The diagnosis is usually made per-operatively. The anatomical lesions are subcapsular hematomes or spontaneous rupture of the liver. Surgery is only treatment and must be conservative. The very high mortality rate has generally been attributable not only to uncontrolled hemorrhage but also to disorders of hemostasis associated and to multiple organe failure.     

Management of spontaneous ruptured hepatocellular carcinoma

Spontaneous rupture is a major life-threatening complication of hepatocellular carcinoma(HCC). Ruptured HCC often causes hypovolemic shock and hepatic hypoperfusion. Patients with impaired liver function tend to lapse into liver failure, which is the main cause of death. To prevent liver failure, accurate diagnosis and adequate treatment for the restoration of the efficient liver perfusion are required. Emergent transarterial embolization (TAE) is the most effective and less-invasive treatment for hemostasis. On the other hand, emergent hepatic resection should be avoided because of the increased risk of postoperative liver failure and incomplete resection of the tumor. After achieving hemostasis, a second-stage therapeutic approach for HCC is required. Patients with acceptable liver function should undergo surgery. The prognosis of ruptured HCC treated with second-stage hepatectomy is considered to be comparable with that of nonruptured HCC. In conclusion, spontaneous rupture of HCC is considered to be a combination of acute and severe peritoneal hemorrhage with malignant disease. To improve the prognosis, adequate early treatment for the control of hemorrhage while preserving liver function is an important factor. TAE followed by elective hepatectomy is considered the most effective treatment.     

Spontaneous rupture of an adenoma of the liver during pregnancy

Must often reporting to an hepatic subcapsular hemorrhage with pre or true eclampsia, Spontaneous rupture of adenoma of the liver during pregnancy is unusual entity. Very exceptionally cases of rupture of anatomic hepatic lesion underlying had been reported. About a new case, diagnosis, physiopathologic and management problems are approached.     

Spontaneous rupture of a giant hepatic hemangioma. Sequential treatment with preoperative transcatheter arterial embolization and conservative hepatectomy

Hemangioma is the most common benign tumor of the liver and it is often asymptomatic. Spontaneous rupture of liver hemangiomas is a rare but potentially lethal complication. Emergent hepatic resection has been the treatment of choice but carries high operative morbidity and mortality. Recently, preoperative transcatheter arterial embolization (TAE) has been used successfully for the management of bleeding ruptured liver tumors and non-operative treatment of symptomatic giant liver hemangiomas. We report a case of spontaneous rupture of a giant hepatic hemangioma that presented with thoracic and abdominal pain and shock due to hemoperitoneum. Once proper diagnosis was made the patient was successfully managed by TAE, followed by conservative hepatic resection.     

Subcapsular hematoma of the graft after liver transplantation

Subcapsular hematoma of the graft is an underreported complication of liver transplantation (LT). Among 408 LT performed from September 1, 1985, to September 1, 2000, eight patients developed a subcapsular hematoma within 30 days after LT (8/408 = 2.0%). Among the six early cases observed, five required further surgical approaches due to hematoma progression, rupture, and hemorrhage. One patient underwent liver retransplantation due to uncontrollable hepatic hemorrhage. The two more recent cases were successfully treated by early opening of the Glisson's capsule with hemostasis of the hepatic raw bleeding surface. The five patients who developed acute renal failure required dialysis. Three patients died during hospitalization. Among the survivors, two were discharged on the postoperative (PO) day 15; the others on PO day 37, 38, and 56. In conclusion, subcapsular hematoma of the graft is a potentially serious complication of LT that may produce severe hemorrhage, shock, and in extreme cases, graft loss or even death. The severity of the complication is related to the extension of the decapsulated area of the graft. An early surgical approach with intentional opening of the hematoma before progression of the lesion seems to facilitate hemostasis and improve results.     

Injuries of blood vessels of the liver during hepatic trauma

Radio-angiograms of 33 severe hepatic trauma casualties were analysed. Five types of injury to the liver were identified according to the anatomical disorders of the organ and their localization: 1) complete rupture of the organ; 2) central ruptures with extension of deep fissures from the caval porta along the hepatic vein and formation of intraparenchymal cavities; 3) multiple moderate and small ruptures of both hepatic lobes; 4) ruptures of the peripheral part of the liver; 5) subcapsular and intrahepatic hematomas, contusion of the liver. Injury to vessels of the first-second order were encountered in complete ruptures of the organ, in all other cases intactness of the vascular system was disturbed at the parenchymatous interlobular level.     

Hepatic trauma revisited

As stated in the introduction to this monograph, much has changed in the management of major hepatic injuries during the past 5 to 10 years. The major changes are summarized as follows: 1. Computed tomographic scanning is now the mainstay of diagnosis for hepatic injuries after blunt trauma and allows for nonoperative therapy in many patients with lacerations, intrahepatic hematomas, or subcapsular hematomas; 2. Realization that the time limit for application of the Pringle maneuver can be extended. 3. Recognition that fibrin glue appears to be a useful topical agent in preliminary clinical studies; 4. Use of hepatotomy with selective vascular ligation instead of mattress sutures for deep lacerations or to control hemorrhage from tracts of penetrating wounds; 5. Use of resectional débridement of devitalized tissue and selective vascular ligation instead of formal anatomical resection; 6. Use of an "omental pack" as a filler of deep cracks or hepatotomy sites instead of closure with mattress sutures; 7. Use of perihepatic packing in selected patients instead of resection when a coagulopathy or major subcapsular hematoma is present; 8. Discontinued use of perihepatic drains for minor or moderate hepatic injuries as long as discrete methods of selective vascular and biliary ligation have been used.     

门静脉分支结扎后门静脉压力变化与肝再生的关系

目的 探讨90%门静脉分支结扎后大鼠门静脉压力变化与肝再生的关系.方法 45只雄性SD大鼠行90%门静脉分支结扎术,其中5只进行假手术作为对照.观察不同时相点门静脉压力和非结扎侧肝脏质量变化,光学显微镜下观察非结扎侧肝细胞的形态学变化,免疫组织化学方法检测未结扎侧肝细胞的增殖细胞核抗原(PCNA),TUNEL法检测未结扎侧肝细胞的凋亡情况,并进行定最分析.采用Pearson相关分析和t检验分析数据.结果 95%(38/40)的大鼠存活.结扎侧肝叶进行性萎缩,非结扎侧肝叶占全肝质量的比例随时问推移而增加,12 h内增加较缓慢,仅为10.75%;而1～5 d则增加速度明显加快,达到27.57%;7～28 d达到平台期,缓慢增加到32.37%.术前门静脉压力为(9.1±1.8)cm H_2O(1 cm H_2O=0.098 kPa);结扎后立即升高,12 h达到高峰(15.8±2.7)cm H_2O,与术前比较差异有统计学意义(t=6.847,P<0.05);1～28 d由(13.6±2.3)cm H_2O逐渐下降为(9.3±2.0)cm H_2O.术前大鼠PCNA阳性细胞计数为7%±3%,术后12 h至3 d由14%±5%上升至21%±6%,第5天达到高峰为26%±7%,与术前比较差异有统计学意义(t=9.129,P<0.05),随后逐渐恢复正常.TUNEL法检测结果显示,术前大鼠肝脏和术后各时相点大鼠未结扎侧肝脏仅见极少量凋亡细胞.大鼠门静脉压力与非结扎侧肝叶肝细胞PCNA的表达在术后1、3、5 d呈正相关(r=0.913,0.896,0.908,P<0.05),在术后14 d时相点呈负相关(r=-0.926,P<0.05).结论 大鼠90%门静脉分支结扎术后,引起未结扎侧肝细胞的活跃再生,再生后的肝脏可恢复原来的质量;肝再生以肝细胞增殖加速为主,而非肝细胞凋亡减少;门静脉压力变化在肝再生过程中可能发挥重要作用.     

Percutaneous angiographic embolization for hepatic arterial hemorrhage

Eight cases of hepatic arterial bleeding are reported. Bleeding in five instances was consequent to trauma and was either persistent postoperative (three cases) or delayed with hemobilia (two cases). Bleeding in the other three cases was from rupture of a subcapsular hematoma of the liver, with spontaneous hepatic rupture of pregnancy (two cases) and metastatic melanoma (one case). Angiography demonstrated pseudoaneurysm in six cases, a hepatic artery to portal venous fistula in one case, and a subcapsular hematoma in the final case. Percutaneous angiographic embolization controlled bleeding in seven cases and was not feasible in one case with tortuosity of the celiac axis. Complications included hepatobiliary necrosis in one patient and subphrenic abscess in two patients. Percutaneous angiographic embolization can selectively occlude a branch of the hepatic artery and is effective in the control of hepatic arterial bleeding from a variety of causes.     

Experimental studies of transcatheter portal embolization

The effects of transcatheter portal embolization (TPE) on energy charge (EC) and hepatic blood flow of the rat liver (HBF) were investigated. The antitumor effects on minimal tumor nodules inoculated into the rat liver via the portal vein were evaluated by the alphafetoprotein (AFP) levels and survival period after TPE. The EC of the embolized lobes was significantly decreased after TPE, as compared with the control groups, but was restored 3h later. The HBF of the embolized lobes was reduced 1h after TPE, but was restored in 1 day when TPE was performed by means of temporary embolus. When permanent embolus was used for TPE, decreased HBF persisted for at least seven days. On the other hand, HBF of the non-embolized lobes was not altered in both groups. When TPE was performed after TAE using temporary embolus, the intervals of 14 days were required for normal liver tissue to be preserved. TPE performed 3 days after inoculation of cancer cells into the rat liver caused prolongation of the survival period and decrease in the level of AFP. These results indicate that TPE does not produce marked damage to the liver and has antitumor effects on minimal tumor nodules. TAE followed by TPE may be useful for therapy of unresectable liver tumor.     

Diagnostic challenges in the evaluation of hepatic grafts from donors with HELLP syndrome: case report and review of the literature

HELLP syndrome (hemolysis, elevated liver function tests, low platelets) is a rare complication of pregnancy that can result in severe complications such as hepatic infarction, subcapsular liver hematomas, and maternal brain death from cerebral hemorrhage. Recently, several investigators have described cases of successful transplantation using livers procured from donors who suffered brain death as a result of HELLP syndrome. However, this new class of marginal liver donors must be approached with caution. We report the case of a 28-year-old pregnant woman who suffered brain death due to HELLP syndrome and was subsequently evaluated for potential liver donation. Although her transaminitis and other liver function tests were markedly improving during the final days of her hospital course, her liver demonstrated segments of necrosis during attempted procurement, and the histology revealed extensive centrilobular necrosis. This case suggests that peak values of serum transaminases, as well as partial resolution of transaminitis, appear to have limited predictive ability in determining the suitability of the hepatic graft for transplantation. Thus, donors with HELLP syndrome should be approached with caution, even in the setting of laboratory values suggesting minimal or resolving hepatic injury. Furthermore, there should be an additional emphasis on obtaining and reviewing histology of the potential graft to determine its suitability for transplantation.     

Imaging and hepatic injuries. Development of a therapeutic strategy and role of non-surgical treatment. 33 cases

Among 67 blunt hepatic traumas treated during a 4 years period, 34 required an emergency surgery for reasons of severe bleeding, with 16 deaths of which 11 were directly due to the liver injury. 33 patients, whose hemodynamic stability contrasted with major hepatic lesions (5 deep fractures, 28 central hematomas combined with 5 subcapsular hematomas and 3 multiple parenchymatous fractures), were subjected to nonoperative management. One patient died from sudden hemorrhage and a second one underwent further drainage for a residual pelvic abscess. In the 32 alive patients, a close watch over with ultrasound and CT scan gave prominence to a complete disappearance of the lesions within 4 to 24 weeks. The nonoperative management of such hepatic injuries may be a safe and reasonable alternative to a high risk surgery, as far as the hemodynamic condition or associated visceral lesions do not require an emergency surgery.     

Liver hemorrhage due to idiopathic peliosis hepatis successfully treated with hepatic artery embolization

Peliosis hepatis is an extremely rare condition that may cause fatal hepatic hemorrhage and liver failure. We report a case of liver hemorrhage due to idiopathic peliosis hepatis. A 60-year-old woman was admitted to our hospital with slight right hypochondriac pain. She went into hemorrhagic shock, and computed tomography (CT) showed multiple low-density areas in the right liver with massive subcapsular blood collection. Selective transfemoral arteriography of the celiac artery revealed no signs of vascular malformation or tumor stain, but showed signs of pooling in the right posterior segmental artery. The artery was embolized with particles of gelatin sponge, and hemostatic control was successful. Although peliosis hepatis is extremely rare, the diagnosis is significant because of its urgent clinical status, and transarterial embolization is a useful and minimally invasive procedure for liver hemorrhage due to peliosis hepatis.     

Effects of preoperative transcatheter arterial embolization (TAE) on the liver following partial hepatectomy in rats

The safety of pre-operative transcatheter arterial embolization (TAE), especially on the relation to hepatic regeneration following partial hepatectomy, was evaluated in rats. TAE was done through a catheter cannulated into hepatic artery under laparotomy. The remarkable elevation of S-GOT and S-GPT levels were demonstrated a day after TAE, which returned to normal on third post operative day. No influence of the difference of embolized materials was seen on the changes of transaminase levels. TAE severely decreased hepatic microsomal functional mass measured by [14C]-aminopyrine breath test (ABT) and the recovery of microsomal functional mass was shown on the 14th day after TAE. Histologically, recanalization could not be revealed in embolized arterioles even on the 21st day after TAE. But trabecular pattern of hepatic lobules was preserved after TAE. The serious inhibition of DNA synthesis of regenerating liver was demonstrated when TAE was performed within 14 days prior to partial hepatectomy (p less than 0.001-0.05). The period from TAE to partial hepatectomy had a influence on the survival rate after partial hepatectomy, and when appropriate interval was taken after TAE, the survival rate increased significantly (33%-50% in 24 hours interval and 88% in 14 days interval). In conclusion, preoperative TAE remarkably suppressed hepatic regeneration after partial hepatectomy, and appropriate time when suppressed hepatic functional mass, such as microsomal functional mass measured by ABT, returned to pre TAE value was required to perform hepatectomy in safety.     

Spontaneous hepatic hemorrhage secondary to retained intraperitoneal gallstones

We describe the first reported case of spontaneous hepatic hemorrhage as a result of retained gallstones in the region of Morison's pouch eroding into the liver parenchyma. The patient presented with acute right upper quadrant abdominal pain 7 months after laparoscopic cholecystectomy. She sustained an episode of limited spontaneous hepatic hemorrhage as noted by abdominal sonography, computerized tomography, and a 4-g/dL hemoglobin drop. Laparoscopic exploration revealed the source of hemorrhage to be an inflammatory source created by retained intraperitoneal gallstones.     

Spontaneous hepatic hemorrhage associated with pregnancy. Treatment by hepatic arterial interruption.

OBJECTIVE. The authors determined the effectiveness of hepatic arterial interruption in treating patients with spontaneous hepatic hemorrhage associated with pregnancy. BACKGROUND DATA. This rare syndrome frequently is seen with eclampsia/preeclampsia and is associated with high maternal mortality. The recommended treatment has been the use of local hemostatic measures. METHODS. The authors reviewed their experience managing eight patients by hepatic arterial interruption. RESULTS. Operative hepatic artery ligation was the initial method of controlling hepatic hemorrhage in three patients. One patient recovered, a hepatic sequestrum developed in one, and one patient died. Three patients survived after hepatic arterial embolization, but a sequestrum developed in one. Two patients died when hepatic arterial interruption was used after failed local hemostatic measures. CONCLUSIONS. The authors believe that hepatic arterial interruption is the preferred treatment for spontaneous hepatic hemorrhage associated with pregnancy. If the diagnosis is made at the time of cesarean section delivery, operative hepatic arterial ligation is indicated. If the diagnosis is made postpartum, percutaneous angiographic embolization should be performed.     

急诊经导管动脉栓塞治疗医源性肝动脉出血

目的探讨医源性肝动脉出血的急诊肝动脉造影表现及经导管动脉栓塞(TAE)治疗的疗效。方法对38例医源性肝动脉出血患者行急诊肝动脉造影,确定出血动脉后,以明胶海绵、PVA颗粒和弹簧圈进行急诊栓塞治疗;对其急诊肝动脉造影表现及TAE疗效进行回顾性分析。结果 38例中,21例肝动脉造影可见对比剂外溢,5例肝动静脉瘘,9例肝动脉假性动脉瘤,3例肝动脉假性动脉瘤合并肝动静脉瘘。急诊TAE后38例出血均停止,总有效率为100%(38/38)。1例术后10天复发出血,再次栓塞治疗后出血停止。随访12个月,所有患者均无肝脏坏死及异位栓塞等严重并发症发生。结论急诊TAE治疗医源性肝动脉出血安全、有效。     

明胶海绵颗粒与Embosphere微球治疗肝癌破裂出血有效性和安全性的对比分析

目的对比分析明胶海绵颗粒及Embosphere微球栓塞肝癌破裂出血靶血管的安全性和临床疗效。方法采用经导管肝动脉栓塞术(TAE),对422例破裂出血的肝癌患者行肝癌出血靶动脉栓塞止血,其中198例采用明胶海绵颗粒栓塞(明胶海绵组),224例采用Embosphere栓塞微球栓塞(微球组),术后结合生化及影像学检查观察和分析临床疗效与不良反应。结果本组422例均有效止血。明胶海绵组中,34例栓塞术后24~36h有复发出血,122例肝转氨酶有不同程度升高(31例转氨酶升至1000U/L以上),198例胆红素均有不同程度上升;微球组中,术后肝功能指标与术前比较差异无统计学意义。结论与明胶海绵栓塞剂比较,Embosphere栓塞微球颗粒治疗肝癌破裂出血具有很好的疗效及安全性,不良反应轻,再通出血概率低,对术后肝功能的损害甚微,有利于围术期患者的良性恢复,值得在临床上推广应用。     

Rupture of a subcapsular liver hematoma in the postpartum period associated with HELLP syndrome

We describe the case of a 31-year-old woman who underwent a section caesarean and 24 hours later a laparotomy for treatment of a ruptured subcapsular liver hematoma due to a HELLP syndrome. The HELLP syndrome (hemolysis, elevated liver enzymes, low platelets count) is a serious complication of the pregnancy with or without eclampsia. This complication has a high mortality and morbidity and can occur during the pregnancy or after delivery. The diagnosis of a subcapsular hematoma of the liver should be considered in patients with acute abdominal pain in the last trimenon or just after delivery. Laparotomy must be performed at the first signs of hemodynamic instability.