Spontaneous retroperitoneal and subcapsular liver hematoma. The ...

Case report Med Ultrason 2013, Vol. 15, no. 2, 157-160DOI:Spontaneous retroperitoneal and subcapsular liver hematoma.The diagnostic contribution of CT, US and CEUS. Case report.Radu Badea 1 , Liliana Chiorean 2 , Calin Mitre 3 , Carolina Botar-Jid 4 , Cosmin Caraiani 21Ultrasonography Department, 3 rd Medical Clinic, “Octavian Fodor” Regional Institute of Hepatology and Gastroenterology,”Iuliu Haţieganu“ University of Medicine and Pharmacy, Cluj-Napoca, Romania2Radiology Department, 3 rd Medical Clinic, “Octavian Fodor” Regional Institute of Hepatology and Gastroenterology,Cluj-Napoca, Romania3Intensive Care Department, 3 rd Surgery Clinic, “Octavian Fodor” Regional Institute of Hepatology and Gastroenterology,”Iuliu Haţieganu“ University of Medicine and Pharmacy Cluj-Napoca, Romania4Radiology Department, Emergency County Hospital Cluj Napoca, ”Iuliu Haţieganu“ University of Medicine andPharmacy Cluj-Napoca, RomaniaAbstractWe present the case of a patient undergoing long-time treatment with oral anticoagulants for a severe vascular pathologywho had a major subcapsular liver bleeding as well as retroperitoneal bleeding. The purpose of the paper is to present thespecific characteristics of this case, to review the literature that concentrates on spontaneous bleedings and to show the role ofcontrast-enhanced ultrasonography as a useful, non invasive imaging method in excluding active hemorrhage and its value inthe non-surgical management of the case.Keywords: subcapsular liver hematoma, oral anticoagulants, contrast-enhanced ultrasonographyIntroductionReceived 23.01.2013 Accepted 16.02.2013Med Ultrason2013, Vol. 15, No 2, 157-160Corresponding author: Prof Radu Badea MD, PhDDepartment of Ultrasonography,3 rd Medical Clinic, Gastroenterology andHepatology Institute,“Iuliu Haţieganu” University of Medicineand Pharmacy,19–21 Croitorilor str400494 Cluj Napoca, RomaniaEmail: rbadea@umfcluj.roAbdominal hemorrhages have numerous causesamong which: trauma, coagulopathies, post surgical conditionsor interventional medical procedures performedeither for diagnosis or therapeutic purposes. Medicalliterature recognizes the term “spontaneous abdominalhemorrhage” as the presence of intra-abdominal blooddue to a non-traumatic, non-iatrogenic cause [1]. Abdominalbleeding due to anticoagulant treatment or hemorrhagicdiathesis (liver failure, hemophilia, idiopathicthrombocytopenic purpura, systemic lupus erythematosus)develops in various places simultaneously, arisingespecially in the abdominal muscles (rectus abdominisor psoas muscle). The abdominal organs are not involvedas often, the hemorrhage in these situations developingin the perirenal space or in the intestinal walls (mainlyjejunum) [2,3]. In patients undergoing chronic oral anticoagulanttreatment gastric hematomas [4] and a few rarecases of bleeding within the lumen or the wall of the gallbladder have been reported [5]. Another possible bleedingsite is the retroperitoneum, which is a rare but lifethreateningsituation [6]. There have been reported rarecases of subcapsular liver hematomas in patients withWegener Granulomatosis [7] and post Imatinib administrationfor treatment of metastatic GIST [8].Imaging explorations have a decisive role in the detectionand characterization of hematomas [9]. The use ofcontrast enhanced ultrasonography (CEUS) as a diagnosisimaging technique on a larger scale may contribute to

158 Radu Badea et al Spontaneous retroperitoneal and subcapsular liver hematoma. The diagnostic contribution of CT, US and CEUSthe change of the therapeutic management in abdominalhemorrhages, from an invasive approach towards a nonsurgicalone, an aspect which has presented an increasedinterest in the last years [10].Case reportA 68 year old patient presented in the emergency departmentfor intense, diffuse abdominal pain, abdominaldistension, epistaxis, and bloody stools. The onset of thesymptoms had been a few days before the presentation andbecame more and more intense, with the peak of intensityin the day before presentation. The patient’s historyincluded a bilateral aortofemoral bypass intervention in1994 for lower limbs arteriopathy obliterans. Since thenthe patient had received chronic treatment with oral anticoagulants(Sintrom 14 mg and Acetylsalicylic Acid 40mg/day). The patient did not report any trauma or infectiousepisodes in recent history and did not use alcohol orany other drugs. The lab investigations performed in theemergency department revealed severe anemia (Hb=7 mg/dl; Ht=27%) as well as important alterations of the coagulationstatus with INR>9 (International Normalized Ratio).The abdominal computed tomography (CT) examinationperformed at presentation revealed the presence of ahypodense fluid collection surrounding the left lobe ofthe liver (fig 1a), as well as fluid in the retroperitonealspace (fig 1b). The patient was admitted into an intensivecare facility for further investigations and therapy.An ultrasound (US) examination was performed (fig 2),followed by a CEUS exam (fig 3) which confirmed thepresence of a large subcapsular liver fluid collection anda second collection, located on the inferior surface of theliver communicating with the first collection. Both fluidcollections were well circumscribed and presented a heterogeneouscontent, with membrane-like echoes inside,an aspect typical for the presence of blood clots. The retroperitonealcollection was also detected. The diagnosisof subcapsular liver hematoma (around the left lobeof the liver) and retroperitoneal hemorrhage was established,the absence of micro-bubbles inside the collectionbeing highly suggestive for inactive hemorrhage.Based on this diagnosis, plasma and blood weretransfused, resulting in a favorable evolution of the patient(within a week from admission the anemia wasresolved, the INR reached normal values and there wasremission of the clinical complaints). The follow up USexamination revealed the tendency of the subcapsularliver hematoma towards organization, while the CT examshowed a reduction of the retroperitoneal fluid collection.The patient was released with an improved status withoutundergoing surgery.Fig 1. CT examination. a) Axial view, arterial phase, showinga hypodense fluid collection around the left lobe of the liver; b)3D reconstruction, coronal view, arterial phase - subcapsularfluid collection surrounding the left liver lobe and fluid collectionin the retroperitoneal space (arrow).Fig 2. Bidimensional ultrasonographic examination, transverseview: a) Subcapsular liver collection - there is an echoic sedimentationinside the collection, suggestive for blood content;b) Subcapsular liver collection and retroperitoneal collection(arrow).Fig 3. CEUS examination. a) Arterial phase - there are no micro-bubblesinside the collection; b) Portal phase - the aspectidentified during the arterial phase is also detected during theportal phase.DiscussionsSubcapsular liver hematomas represent an accumulationof blood between the capsule of Glisson and theliver parenchyma. They are frequently located around theright lobe (about 75 % of cases) and the rupture of thehematoma into the peritoneum is associated with a high

mortality rate [11]. The development mechanism of subcapsularliver hematomas, as well as their self-limitingcharacter is conditioned by the anatomy of the liver capsule.This is made of two layers: the first is the viscerallayer (capsule of Glisson) in close contact with the liverparenchyma, and the second is actually a reflection of theperitoneum sustaining the liver in contact with the diaphragm(hepatodiaphragmatic ligament) [12]. Since thecapsule of Glisson is fibrous and has no elasticity, theshape of the hematoma is convex towards the parenchyma,an aspect that helps to distinguish a hematoma fromother perihepatic not subcapsular collections, in whichthe shape of the liver is not modified by compression.The symptoms of liver hematomas are not specific, thelaboratory studies reveal anemia and coagulation alterationsand the final diagnosis is established through imagingtechniques (ultrasonography and CT) [1,13].The necessity of an early and accurate diagnosis insubcapsular liver hemorrhages derives from the moderntrend of treating them conservatively, especially when thepatient is hemodynamically stable [10]. Therefore a lot isexpected from imaging procedures. On the CT examinationa subcapsular liver hematoma typically looks like alenticular, ellipsoid, perihepatic collection with a densitythat on the non-enhanced exam depends on the “age” ofthe hematoma. Acute hematomas are typically hyperdense(40-60 HU), due to the high protein content. The densitydecreases in time due to the progressive lysis of hemoglobinbecoming hypodense in the chronic phase [14].The ultrasonographic appearance of hematomas variesdepending on their localization and “age”: a recenthematoma has a fluid-like aspect, transonic and, wellcircumscribed by the capsule of the organ; there can besedimentation inside or even intense echoes generated bythe blood clots. In time, a few days after formation, thehematoma becomes echoic by condensation and theaccumulationof clots [15]. Therefore, the main diagnosiscriteria is represented by changes in the aspect of thecollection from one day to another, the resorption of thecollection being influenced by the context in which thehemorrhage has occurred, comorbidities, continuous orceased bleeding and the volume of the bleeding.Regarding the evolution of the hematoma, CEUS isextremely useful as a diagnosis and follow up imagingmethod. Once the blood collection is detected, CEUShelps to better evaluation and measurement [16]. An enhancementof parenchyma that surrounds the collectionis registered during the arterial phase and the aspect persistsduring the venous and delayed phases. The methodis very sensitive in detecting active bleeding by visualizingthe echoes inside the collection as well as in detectingpossible vessels malformations that can cause the bleed-Med Ultrason 2013; 15(2): 157-160 159ing [17]. CEUS is a “real-time”, non-invasive, bedsideinvestigation that does not require radiation exposure andis an adequate choice for the evaluation of abdominalsolid organs in patients that have contraindications forCT contrast media administration or are hemodynamicallyunstable [18].There is quite an abundance of literature regardingspontaneous hemorrhages and the value of imaging fordiagnosis. The specific features of this case are representedby the fact that a spontaneous, massive subcapsularliver hematoma in a patient with an excessive intake ofanticoagulants is rare and the association with spontanretroperitoneal bleeding is even rarer. We also wantedto highlight the use that CEUS had to confirm that thebleeding has stopped. The diagnosis algorithm that wasused, based on the imaging data, led to a non-invasivetherapeutic approach. The complexity of the differentialdiagnosis must also be underlined, as the magnitude ofthe hemorrhage, both subcapsular and retroperitoneal,raised significant differential diagnosis problems, bothon the CT and US images. Therefore, in this case, thecorrelation of the imaging data with the patient’s historywas very important.Conclusions: Imaging investigations allow the detectionof internal hemorrhages and help establish theorgan which is involved, the site, the extent and the evolutivefeatures of the bleeding. CEUS is useful to consolidatethe clinical diagnosis of a stopped hemorrhage.The hemorrhagic character of a fluid collection is demonstratedby observing the changes of the US aspect indynamic examination. When there is hemodynamic stabilitythe imaging data are sufficient for the diagnosis inemergency situations, making other invasive proceduresunnecessary.References1. Furlan A, Fakhran S, Federle MP. 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