Bilateral Lower Limb Edema Caused by Compression of the Retrohepatic Inferior Vena Cava by a Giant Hepatic Hemangioma

Hemangiomas are the most common benign primary tumors of the liver and their prevalence ranges from 0.4% to 20%. Approximately 85% of hemangiomas are clinically asymptomatic and are incidentally detected in imaging studies performed for other causes. In a very small minority of patients, nausea, vomiting, abdominal pain, distension, palpable mass, obstructive jaundice, bleeding, and signs and symptoms of Budd-Chiari syndrome may develop due to compression of bile duct, hepatic vein, portal vein, and adjacent organs. Occasionally, external compression of inferior vena cava may lead to edema and/or indirect symptoms such as deep vein thrombosis of the lower limbs. In this report, we present a case of giant hepatic hemangioma that completely filled the right lobe of the liver. The patient presented with bilateral lower limb edema and pain. A computed tomography scan detected a 9 × 11 × 12 cm mass indicative of a hemangioma in the right lobe of the liver that compressed the inferior vena cava. The patient refused treatment initially but returned 6 months later presenting with the same symptoms. At that time, the mass had increased in size and a hepatectomy was performed, preserving the middle hepatic vein. By postoperative month 13, the swelling in the lower extremities had decreased significantly and the inferior vena cava appeared normal.     

Tödliche Zwischenfälle durch Menschengedränge bei Großveranstaltungen

Background

Crowd crushes with dozens or even hundreds of casualties have occurred several times at the Hajj in Saudi Arabia and also in soccer stadiums in Western Europe. As fatal accidents after human stampedes during mass events occur very rarely and are usually accompanied by many years of criminal court proceedings in order to identify underlying responsible mechanisms and culprits, it is very difficult to draw conclusions and formulate precautions from an emergency medical point of view.

Methods

This study analyzed a fatal crowd crush which occurred on 4 December 1999 following the “Air & Style” snowboard contest with approximately 22,000 people attending in the Bergisel stadium in Innsbruck, Austria. Firstly, focused interviews were conducted with professional rescuers, police and physicians and secondly publicly available court records dealing with this incident in the district court of Innsbruck, Austria were analyzed.

Results

During the snowboard contest 87 emergency medical technicians, 6 emergency physicians, 1 leading emergency physician, 21 policemen and 140 security personnel were present. Following the accident additionally some 100 emergency medical technicians, 36 emergency medical service vehicles and 4 physician-staffed emergency medical service vehicles responded to the scene. The deadly crowd crush resulting in 6 fatalities, 4 patients still in a vegetative state and 38 injured, was due to a severe crowd accumulation at one stadium exit, which was not recognized and dispersed in time. Construction of the exit in line with darkness, steep slope and slippery surface contributed adversely to this dangerous situation, although panic did not occur at any time.

Conclusions

Unfortunately, there is no patent remedy to completely prevent fatal accidents by a crowd crush at mass events. If planning is initiated early, sufficient material and personnel reserves are kept in reserve and despite conflicting interests of the organizers, the host community, security, police and emergency medical services, a joint concept is designed and followed, the risk of a severe incident can be kept to a minimum. Each involved party including the spectators have to be aware of their responsibility in order to contribute to the success and safety of the mass event. A comprehensive and critical review of all facts and implementation of conclusions implies a time and financial burden but has a positive impact on the success and safety of mass events.