AoP J Biomed Clin Res Volume 14 , 2021 DOI: 10.2478/jbcr-2021-0014 Case Report INTRAHEPATIC HEMATOMA AND HAEMOBILIA AFTER PERCUTANEOUS LIVER BIOPSY: A CLINICAL CASE REPORT Goran Sarafiloski, Summary Mimi R. Marinova, Pencho T. Tonchev1 Assessing the severity of liver disease and predict the response to treatment in clinical practice requires the determination of the degree of inflammation progression and liver Department of Gastroenterology, fibrosis. Percutaneous liver biopsy is the gold standard for Medical University – Pleven grading and staging liver diseases. Complications are more 1Department of Surgery, common in the presence of vascular liver lesions, dilation Medical University – Pleven of the bile ducts, ascites, or whether examination has been performed by less experienced physicians. Bleeding after liver biopsy is considered the most common cause of severe complications. Bleeding usually presents as a subcapsular or parenchymal hematoma, free intraperitoneal hemorrhage, hemobilia, or, rarely, hemothorax. The rarest of hemorrhagic complications is hemobilia, a term used to describe bleeding in the bile ducts. Hemobilia is usually suspected when there is a drop in hemoglobin after the procedure, pain in the upper right quadrant of the abdomen, hyperbilirubinemia, and unexplained gastrointestinal bleeding. The clinical manifestations range from chronic anemia to rapid, massive bleeding with hematemesis and/or melena. Keywords: liver biopsy, complication, intrahepatic hematoma, hemobilia, melena Introduction We present a patient with intrahepatic hematoma and hemobilia after liver biopsy performed on a chronic viral hepatitis C for specific antiviral treatment. Liver biopsy (LB) plays a crucial role in the algorithms for diagnosis and treatment in patients with chronic liver disease and remains the gold standard for assessing liver pathology. To determine the severity of liver damage and predict treatment response in Corresponding Author: clinical practice, the degree of inflammation and liver Goran Sarafiloski fibrosis have to be evaluated. Liver biopsy is performed Department of Gastroenterology, by various techniques – percutaneous, transjugular, Medical University – Pleven and laparoscopic. The latter two manipulations are 1, St. Kl. Ohridski Str. performed in the presence of relative contraindications Pleven, 5800 Bulgaria for percutaneous liver biopsy [1,2]. e-mail: [email protected] Absolute contraindications for liver biopsy are: • severe hemostasis disorders, hemorrhagic diathesis; • purulent-inflammatory changes in the abdomen, Received: March 31, 2021 pleura, the liver itself because of the risk of Revision received: May 10, 2021 spreading the infection (pleurisy, empyema, Accepted: July 08, 2021 cholangitis, acute cholecystitis, subphrenic or other abscesses); i © Medical University Pleven AoP J Biomed Clin Res Volume 14 , 2021 • pustular or eczematous processes, dermatitis showed that in about 50 percent of the cases, it at the points of the planned puncture or was caused by trauma, followed by iatrogenic incision; causes in one-third of the cases. The most • severe portal hypertension; common cause reported is needle biopsy of the • massive ascites; liver [8,9]. • focal processes in the liver (vascular lesions, cystic formations - echinococcal cysts, Case Report tumors); zA 56-year-old patient with proven liver cirrhosis • extrahepatic cholestasis; since 2003 based on chronic HCV infection since • changes in the anatomy of the bile ducts; 1996 was diagnosed by blood donation. He had • lack of liver dullness (small liver, severe suffered several hemorrhages from esophageal emphysema, Chilaiditi’s syndrome); varices, the first of which was in 2003. In • disorders of consciousness, coma; 2005 he was operated on for hemorrhage from • mental illness in which contact with the esophageal varices. Splenectomy was performed patient is difficult. due to severe hypersplenism syndrome. Since Relative contraindications for liver biopsy then, several endoscopic ligations of the varicose include: veins had been performed. He received constant • heart or respiratory failure; therapy with Propranolol 20-40 mg, depending • hypertension; on the values of blood pressure, as well as • severe anemia; hepatoprotectors and diuretics. • severe cachexia; The patient was admitted for liver biopsy for • obesity; staging and grading the disease, and a protocol • allergy to local anesthetics; was to be prepared for specific antiviral treatment • the disagreement of the patient. following the requirements of the National Focal processes in the liver are diagnosed Health Insurance Fund. by abdominal ultrasound. [3,4]. Preliminary Results from laboratory tests were as laboratory tests are performed – complete blood follows: revealed tests: leukocytes – 3.9x109/l, count, coagulation status, biochemistry. The hemoglobin – 127g/l, platelets – 173x109/l, patient should be informed about the whole ALT – 81UI/l, AST – 114UI/l, GGTP – 98UI/l, procedure and possible complications and sign AF – 72UI/l, total bilirubin – 23mmol/l, direct an informed consent. bilirubin – 13mmol/l, prothrombin time – 71.1%, According to literature data, complications INR – 1.23. after liver biopsy occur in 1-5% of patients. Abdominal ultrasound revealed diffuse About 60% of complications appear within two structural disorders of the liver parenchyma. hours after the procedure, and 96% – by the There was no evidence of free intraperitoneal twenty-fourth hour [4,5,6]. The frequency of fluid. complications correlates with the diameter of The patient underwent LB without the needle, the time it is held in the liver, and complications. After the manipulation, CBC the depth to which the needle inserts into the showed – leukocytes – 4.8x109/l, hemoglobin – liver tissue. Possible complications are pain, 126g/l, platelets – 173x109/l. bleeding, damage to a neighboring organ (lung, Six days after the liver biopsy, the gallbladder), or infection. Hemorrhage, biliary patient reported severe colic pain in the right peritonitis, and pneumothorax are potentially hypochondrium, nausea, vomiting, and black fatal. Bleeding is observed at 0.32-0.35%. stools. Mortality from severe bleeding is 0.11% [6,7]. The results from the control laboratory It presents as a subcapsular or parenchymal tests were as follows: leukocytes – 10.8 x109/l, hematoma, intraperitoneal hemorrhage, hemoglobin – 103g/l, platelets – 184x109/l, hemobilia, or, rarely, hemothorax. ALT – 65UI/l, AST – 78UI/l, GGTP – 226UI/l. The rarest of hemorrhagic complications Total bilirubin – 195mmol/, direct bilirubin – is hemobilia. This term was first used in 1946 179mmol/l, prothrombin time – 70.5, INR – 1.2. by Sandlom to describe bleeding from the bile Abdominal ultrasound showed enlargement ducts. A review of Sandblom‘s hemobilia cases ii © Medical University Pleven Sarafiloski G., et al. Intrahepatic hematoma and haemobilia after percutaneous ... of the liver with a non-homogeneous structure of Discussion the parenchyma. The lateral part of the right lobe next to the gallbladder, an anechogenic zone with Liver biopsy is an invasive and, therefore, dimensions 127/55 mm, with hyperechogenic potentially dangerous procedure, widely used areas inside it (hematoma) was visualized. There for diagnosis and evaluation of various liver was a minimum amount of free fluid in the diseases, including chronic HCV infection. abdomen. Complications are observed in 1-5% of the CAT confirmed the presence of a hematoma. cases. Therefore, it is only in a hospital setting. On gastroscopy, varicose veins of the Hemorrhage and biliary peritonitis are esophagus, blood in the lumen of the stomach detected in the first 4 hours after the procedure. and duodenum were seen. Delayed bleeding occurs within 15 days After consultation with a surgeon and after biopsy [10], and 23% of the patients are resuscitator, a decision was made for surgical diagnosed with subcapsular or intrahepatic treatment of the patient in the Clinic of hematoma in the first 24 hours after the procedure Abdominal and Visceral Surgery. Exploratory using abdominal ultrasound. These hematomas laparotomy revealed the presence of a hematoma are usually small and do not lead to serious located between the porta hepatis, the lesser hemodynamic disorders [6,11]. curvature of the stomach, and the gallbladder. Most cases of fatal bleeding, especially The hematoma (about 300 ml of old, hemolyzed hemoperitoneum, result from perforation of a blood) was evacuated. The hematoma cavity vessel from the portal or hepatic blood circulation. was treated with HaemoCer™, and three It can also occur because of a rupture of the liver hemostatic sponge strips were inserted. Bleeding when the patient takes a deep breath during in the liver was also found, which was sewn to the biopsy [11]. Hemoperitoneum occurs in achieve hemostasis, and a thorough lavage with 0.32% of the cases and clinically manifests with aspiration was performed. A subhepatic drain abdominal pain, hypotension, and tachycardia. It was placed. may be diagnosed with abdominal ultrasound or Postoperatively, therapy was continued computed tomography [8]. in the Intensive Care Unit with saline water Hemobilia is suspected in patients with a resuscitation, hemostasis, blood transfusion, decrease in hemoglobin level after the procedure antibiotics, and a nil per os diet. Despite the and the presence of pain in the upper right therapy, the patient’s condition did not improve, quadrant of the abdomen, changes in vital signs the hemodynamic