Spontaneous liver rupture: A report of two cases.

Spontaneous bleeding due to a non traumatic liver rupture is a rare occurrence. However, it is associated with high morbidity and mortality. Usually the predisposing factors are like Hemolysis, elevated liver enzymes, and low platelet count (HELLP) syndrome in pregnant women and other liver diseases. It is generally diagnosed by imaging studies such as ultra sonogram or computerized tomogram (CT). Due to its rarity no standard treatment has been described. Here, we report two cases of spontaneous rupture of normal liver in two young males. They presented with severe shock and hemoperitoneum. The diagnosis was confirmed by CT. They were managed surgically. In case of hemoperitoneum, spontaneous liver rupture should be considered. An early aggressive resuscitation and appropriate intervention gives better outcome.

INTRODUCTION

Non traumatic liver rupture is rare. It is common in pregnant women with Hemolysis, elevated liver enzymes, and low platelet count (HELLP) syndrome and some liver diseases and very rarely occurs among healthy individuals. It is usually diagnosed by imaging studies such as ultra sonogram or computerized tomogram (CT) or may be as a surprise finding in emergency laparotomy. A few cases have been reported in the literature. We report two patients presented with hemoperitoneum due to liver rupture with no etiological cause or abdominal trauma and were managed surgically.

CASE REPORTS

Case 1

A 26-year-old man presented to emergency department with abdominal pain for five days. He had no vomiting or altered bowel habits. There was no history of trauma or other co-morbidities. On admission he was in shock with heart rate of 120 per minute and blood pressure not recordable. Abdomen was distended and non tender. There were no signs of peritonitis. Laboratory investigations showed hemoglobin of 5.4 gm/dl, white cell count 7.800/cmm, platelet count 1.3 lacs/ccL and INR 1.01. Liver function tests showed normal bilirubin, albumin, and enzymes.

Focused abdominal sonogram for trauma (FAST) showed free fluid with hyper echoic area in the abdomen. Hemoperitoneum was suspected and contrast-enhanced CT revealed large sub capsular hematoma with hemoperiotneum. There were no cysts or hemoangiomas of the liver. At emergency laparotomy, there was two liters of altered blood in the peritoneal cavity with a large ruptured hematoma over the seven and eight segments of the liver. Other solid viscera and bowel were normal. Peritoneal wash and peri hepatic packing was done with gel foam. He received six units of blood. The routine investigations for common conditions with liver rupture were normal. He had uneventful post operative period and recovered with no morbidity. The HPE of the liver tissue revealed extensive hemorrage and mild to moderate steatosis. He was asymptomatic on follow-up a year ago [Figure 1].

Figure 1

(Case 1) Pre operative computerized tomogram (CT) scan showing peri hepatic hematoma

Case 2

A 37-year-old male attended the emergency department with history of severe abdominal pain and bilious vomiting for a month, exacerbated for few days. There was no history of hematemesis or altered bowel habits. He had no other co-morbidities or past illness. While waiting in the emergency department he suddenly collapsed and was unresponsive. He was intubated and adequately resuscitated. Abdomen was distended and no mass was palpable.

Laboratory investigations showed hemoglobin of 4. gm/dl, white cell count 15/cmm, platelet count 1.3 lacs/ccL and INR 1.01. Liver function tests showed normal bilirubin, albumin, and enzymes. FAST showed free fluid in the abdomen. At emergency laparotomy there was hemoperitoneum with clots around the liver and a large raw area with breach in the capsule in the segment six and seven. Perihepatic packing was done. He was monitored in the Intensive Care Unit and packs were removed during relaparotomy after 48 hours. He slowly improved and was discharged after seven days of hospitalization with no disability. The HPE of the liver tissue revealed mild inflammation. He was doing well on follow-up for six months [Figure 2].

Figure 2

(Case 2) Post operative CT scan showing persistent perihepatic hematoma

DISCUSSION

Atraumatic spontaneous liver rupture is a serious condition with high morbidity and mortality. It is usually seen in pregnant women with HELLP syndrome. It occurs in 1-2% of cases of pre eclampsia and eclampsia.[1] Other causes are primary, benign, and malignant liver tumors, liver cirrhosis, amyloidosis, malaria, venous stasis, secondary tumors in the liver, and hypereosiniphilic syndrome.[2] Hepatic rupture is common in the right lobe of liver due to larger size.[3]

Usually patients may present with abdominal pain and distension for shorter duration. In acute phase patients may present with shock and hemoperitoneum. Due to rarity of these and low index of suspicion the diagnosis is delayed.[4] Diagnosis is confirmed by imaging studies such as ultra sonogram and contrast-enhanced CT scan. Interventional radiological procedures like angiography are useful for both diagnosis and therapy.[5]

Different theories have been postulated for spontaneous rupture of liver. In HELLP syndrome, vasospasm from increased sensitivity to circulating vasopressors during pregnancy and vascular injury from endothelial damage leads to formation of micro vascular thrombi that result in rupture.[6] In amyloidosis, thromboses is due to liver enlargement, rigidity of hepatic parenchyma, and vascular fragility.[7] In HCC and other malignant liver lesions, the pathogenesis of spontaneous liver rupture maybe due to the overlying normal liver parenchyma splitting from the expanding tumor growth.[8]

After confirmation of diagnosis in stable patients with intact liver capsule and contained hematoma, conservative treatment with serial haemoglobin monitoring, ultra sonogram or CT is required. In unstable patients emergency laparotomy, peri hepatic packing, or liver resection can be done. Stable patients who are diagnosed to have an aneurysm, interventional radiological procedures like angiographic coiling or embolization pre operatively or during the surgery is an option. Stain et al. reported six cases managed by angiographic embolisation and hepatic artery ligation.[9] In pregnant women with spontaneous rupture of liver an elective caesarian section is advised to prevent the precipitation of hepatic rupture.

In both cases bleeding stopped with perihepatic packing. In conditions where perihepaitc packing is not useful, liver resection can be done.[10] In severe cases with uncontrolled bleeding liver transplantation may be the only option but there have been no reports so far in the literature.[3]

CONCLUSION

Spontaneous liver rupture is to be considered in cases of atraumatic hemoperitoneum. High index of suspicion required for early diagnosis and intervention to reduce morbidity and mortality. Surgical or radiological procedures help for good outcome.