Spontaneous Hepatic Hemorrhage: A Single Institution's 16-Year Experience

Abstract

Spontaneous hemorrhage from hepatic tumors is an uncommon but serious complication. Recently, interventional radiologic (IR) techniques are being used increasingly in the management of these patients. We report our 16-year experience in managing spontaneous hemorrhage from liver tumors. Twenty-six consecutive patients were diagnosed with spontaneous liver hemorrhage between 1995 and 2011. Initial management was operative in eight, IR in six, and supportive in 12 patients. Of those managed operatively, five were segmentectomies; one hemihepatectomy; one wedge resection; and one packing who later died from coagulopathy. In the IR patients, seven had an angiographic embolization; two required reembolization; one underwent resection of a hepatic adenoma 21 days after angiographic embolization. The malignant lesions included hepatocellular carcinoma (n = 6), angiosarcoma (n = 1), metastatic squamous cell carcinoma (n = 1), metastatic leiomyosarcoma (n = 1), nonsquamous cell carcinoma (n = 1), or metastatic angiosarcoma (n = 1). Benign diseases included hepatic adenoma (n = 5), end-stage liver disease (n = 1), and polycystic liver (n = 1). Spontaneous hemorrhage from the liver occurs evenly from benign or malignant causes, one-third of which are primary liver disease. If the patients presents emergently, angiographic embolization may control the bleeding and allow for elective resection once the sequelae of bleeding have resolved.

Segment V spontaneous hepatic haemorrhage from hepatic cirrhosis: an emergency abdominal surgery case report

“…If the patients presents emergently, angiographic embolization may control the bleeding and allow for elective resection once the sequelae of bleeding have resolved. 3,10,11 A spontaneous hepatic haemorrhage (SHH) is a rare condition that results from a breach in the hepatic parenchyma that occurs without an external cause. It is an acute surgical emergency as it results in intra-abdominal bleeding that, if untreated, will progress to haemorrhagic shock and death.…”

“…In spite of these issues, SHH has never been comprehensively reviewed possibly because of its rarity, the potentially wide range of underlying conditions and the fact that many publications in the area are small series of less than five patients or case reports. 1,3 SHH is a rare event most commonly caused by HCC and hepatic adenoma although there are numerous other causative lesions including all recognized benign and malignant hepatic tumours including metastatic cancer. The mechanism of spontaneous bleeding remains unclear but there is evidence for compromised vascular integrity at least in patients with HCC and the incidence of the condition in patients with connective tissue diseases (amyloid and SLE) and polyarteritis nodosa indicates that this is an important factor in the pathogenesis of the condition.…”

“…Cross-sectional imaging with CT scanning is the mainstay of diagnosis and initial management emphasizes the use of arterial embolization to obtain haemostasis with a hepatectomy reserved for patients with bleeding tumours after formal staging and assessment of their liver function. 3,10,12 Another cause of spontaneous hepatic haemorrhage is rupture of the liver tumor. Hepatic hemangioma is the most common benign liver tumor, with the majority being cavernous hemangiomas, with little chance of malignant transformation.…”

“…In spite of these issues, SHH has never been comprehensively reviewed possibly because of its rarity, the potentially wide range of underlying conditions. 2,3 A diagnosis of SHH is based on a clinical index of suspicion in patients with a known underlying condition. However, this is not always as straightforward as SHH is a rare complication in patients with connective tissue disease.…”

“…Initial workup should include an assessment of liver function, coagulation status with the emphasis on defining and quantifying underlying hepatic function and the presence of cirrhosis. 1,3…”