HELLP syndrome and ruptured subcapsular hepatic haematoma. Case report and therapeutic options

We report a case of spontaneous hepatic rupture secondary to HELLP syndrome. A favourable evolution was observed after massive transfusion and surgical management limited to hepatic packing. Subcapsular hepatic haematoma is a rare complication of preeclampsia occurring mainly in the context of HELLP syndrome. A high maternal and foetal mortality is observed. Different therapeutic options are presented including medical, surgical and radiological interventions. A unique strategy cannot be defined. Multidisciplinary approach seems mandatory. Surgery should remain as less aggressive as possible.     

自发性肾包膜下和肾周血肿的诊断与治疗

目的 提高对自发性肾包膜下和肾周血肿的诊断与治疗水平。方法 对17例自发性肾包膜下和肾周血肿病例的临床及随访资料进行回顾性分析,诊断采用B超、CT和血管造影等影像学检查手段。17例中,肾切除手术13例,肾活检术1例,其余保守治疗。结果 随访6－108个月,死亡3例,其余均健在。结论 影像学是诊断本病的重要手段,CT最有诊断价值。治疗方法应根据病因决定,多数以手术为主。     

Spontaneous renal subcapsular haematoma and acute renal failure complicated by severe pre-eclampsia.

Sir, Spontaneous renal subcapsular haematoma is rare and seldom suspectedclinically. The characteristic clinical features are abdominalpain, a mass in the flank and signs of internal bleeding. Theknown causes of spontaneous renal subcapsular haematoma aretumours, vascular diseases, infectious diseases, severe pre-eclampsiaand blood dyscrasias [1,2]. Because renal     

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.     

Nonoperative management of subcapsular hematomas of the liver

The liver is the second most common organ injured in blunt abdominal trauma, and with the use of diagnostic techniques such as hepatic scanning, an increasing number of patients with intrahepatic lesions are being identified. Five patients with this type of lesion are presented. A plan of management, including observation in an intensive care unit, repeated physical examinations, frequent reevaluation of laboratory values, bed rest, gastrointestinal tract decompression and broad spectrum antibiotics, is suggested as the treatment of choice for this type of injury. All patients in the series have done well with no abscess formation, delayed rupture or hemobilia, and all show resolution of the defect on follow-up hepatic scanning.     

Laparoscopic liver resection for subcapsular hepatocellular carcinoma complicating chronic liver disease

HYPOTHESIS: Laparoscopic liver resection for subcapsular hepatocellular carcinoma in patients with chronic liver disease is associated with lower morbidity than open resections. DESIGN: A case-comparison study. SETTING: A tertiary referral center. PATIENTS AND INTERVENTION: From December 1, 1998, to November 30, 2000, 13 patients with chronic liver disease who underwent laparoscopic resection of hepatocellular carcinoma formed the laparoscopic group (LG). Tumors were 5 cm or smaller, subcapsular, and located in anterolateral segments (segments II-VI). A control group was created by matching each laparoscopic case with patients identical for liver disease, tumor size, and location and type of hepatectomy who underwent open liver resection. Fourteen patients fulfilled the criteria and formed the open group (OG). MAIN OUTCOME MEASURES: Postoperative mortality and morbidity. RESULTS: One segment or less was resected in 21 patients and 2 in 6 patients. Operative duration and cumulative portal triad clamping times were longer in the LG (267 +/- 79 minutes vs 182 +/- 57 minutes, P =.006; 68 +/- 24 minutes vs 25 +/- 19 minutes, P =.006, respectively). Mortality rates were 0% in the LG and 14% (2/14) in the OG (P =.2). Postoperative liver failure and ascites occurred in 8% (1/13) in the LG and 36% (5/14) in the OG (P =.15). Surgical margin was not different in the 2 groups. Three-year survival was significantly higher in the LG (89% vs 55%; P =.04), but 3-year recurrence rates were similar (46% vs 44%). CONCLUSION: Our study suggests that, despite longer operative and clamping times without clinical consequences, the rate of decompensation of liver disease could be lower after laparoscopy.     

Large subcapsular liver hematoma following single-incision laparoscopic cholecystectomy

Background and Objectives:

Many laparoscopic surgeons are now transitioning from standard multiple-port laparoscopic cholecystectomy to single-incision laparoscopic surgery (SILS) in an attempt to improve cosmetic outcomes and decrease postoperative morbidity. However, little has been published regarding the potential complications of SILS operations.

Methods:

We report the case of a patient undergoing SILS cholecystectomy who developed the complication of a large hepatic hematoma, resulting in significant postoperative morbidity, blood transfusion requirement, and reoperation.

Results:

After an in-depth internal review of the postoperative morbidity of this case, it appears that the causative factor may be instrument shaft torque on the liver surface.

Conclusion:

Single-incision laparoscopic surgery may pose significant and unique risks that warrant additional operative caution. Quantitative comparison of SILS to the gold-standard laparoscopic cholecystectomy is needed to further elucidate definitive benefits and complications of this novel technique.     

Penetrating gastric ulcer presenting as a subcapsular liver abscess

This report describes a subcapsular liver abscess secondary to a penetrating gastric ulcer. The initial read on the CT scan misinterpreted the abscess cavity as an opacified loop of bowel, although it was very conspicuous on a retrospective review. A penetrating gastric ulcer was identified with esophagogastroduodenoscopy and the subcapsular liver abscess was subsequently detected using MRI. Although the conventional treatment of this condition is surgery, successful management was accomplished with a combination of percutaneous drainage, Helicobacter pylori eradication, and acid-suppressive therapy. A review of the literature is provided, including associated cases and the diagnostic modalities used in the evaluation of this condition. This case illustrates how one can arrive at the correct diagnosis with the use of multiple complementary modalities of investigation.     

Human Kluver-Bucy syndrome following acute subdural haematoma

Summary. We present a rare case of complete human Kluver-Bucy syndrome (KBS) following recovery from transtentorial herniation caused by acute subdural haematoma (ASDH). A 17-year-old right-handed high school boy got into stupor within five minutes after 3-rounds of sparing at boxing. Emergency computed tomographic (CT) scan showed right cerebral hemispheric ASDH, which was evacuated following intentional decompressive craniectomy. After recovery of consciousness, he developed emotional changes (placidity with loss of normal fear and anger), psychic blindness, aberrant sexual behaviour, excessive oral tendencies, increased appetite, and hypermetamorphosis in order of mention, which were observed with waxing and waning from 17th to 28th hospital day. Peri-operative CT scaning and magnetic resonance imaging showed lesions of the right temporal lobe and right-dominant orbitofrontal regions including bilateral rectal and medial orbital gyri, and the intact left temporal lobe. Two pathogeneses can be thought of and the whole picture of KBS following ASDH can arise even though one (left in this case) temporal lobe is preserved, 1) in which associated orbitofrontal lesions of the frontal lobes may correlate with occurrence of KBS, or 2) cerebral blood hypoperfusion of both temporal lobes due to increased intracranial pressure and/or compression of both posterior cerebral arteries at the edge of the tentorium cerebelli occurs.     

Treatment of subcapsular haematoma, a complication of extracorporeal shock wave lithotripsy (ESWL), by percutaneous drainage.

Case A 54-year-old man presented to the emergency room with leftflank pain following an extracorporeal shockwave lithotripsy(ESWL). He had undergone ESWL for a left renal pelvis stone1 month prior to the admission. His symptom began about a day