Apixaban Causing Hepatic Cystic Bleeding: A Rare but a Life-Threatening Complication

Abstract

Cystic lesions of the liver are a heterogeneous group of disorders with varied etiology, prevalence, and clinical manifestations. Fibropolycystic liver disease encompasses a spectrum of related liver and biliary tract lesions caused by abnormal embryologic development of the ductal plates. These disorders include congenital hepatic fibrosis, biliary hamartomas, polycystic liver disease (PCLD), choledochal cysts, and Carolis disease. PCLD is arbitrarily defined as a liver that contains >20 cysts. Most liver cysts are incidentally found on imaging studies, and the majority of the patients with liver cysts are asymptomatic. Rarely, complications such as compression, infection, and bleeding within the cyst can occur. Under the effect of the increased pressure, the epithelial lining of the cyst undergoes necrosis and sloughing, causing injury of the fragile blood vessels, leading to intracystic bleeding. The bleeding within or from the cyst can be precipitated by anticoagulation. We present a patient with PCLD who developed intracystic bleeding after he was started on apixaban for the prevention of thromboembolism.

EASL Clinical Practice Guidelines on the management of cystic liver diseases

“…Intracystic haemorrhage results from injury to fragile blood vessels of the cyst wall lining and is by far the most frequent complication of hepatic cysts. Cyst haemorrhage is mostly seen in patients with larger (arbitrarily defined as >8 cm) cysts 104 and may occur spontaneously, as a complication of percutaneous aspiration sclerotherapy, or as a consequence of a cyst rupture.…”

ADPKD, COVID-19, and Apixaban: The Treacherous Intracystic Bleeding – A Letter on Apixaban Causing Hepatic Cystic Bleeding by Shehi et al.

“…Histopathology discovered a fibrotic cyst wall with hemosiderin deposition and features of fibro-polycystic liver disease. After surgery, he recovered and was successfully discharged home [ 1 ].…”

“…In both situations, there may be a treacherous inflammasome activation [ 5 , 6 ]. In addition, there is recent evidence that the use of apixaban should be cautiously balanced between pros and cons in patients with end-stage renal disease or multiple hepatic and renal cysts, as seen in Shehi et al's [ 1 ] patient [ 7 , 8 , 9 , 10 ].…”

“…Dear Editor, Shehi et al [1] report on a 69-year-old Hispanic man who presented to the hospital with complaints of right upper quadrant pain for the past 3 days without any history of trauma to the abdomen. Multiple renal and liver cysts were incidentally diagnosed 2 years previously during a routine ultrasound in the patient's medical history.…”