Arrest of Liver Haemorrhage Secondary to Percutaneous Liver Biopsy of a Haemangioma with Fibrin Glue

Abstract

Background

Haemorrhage resulting from blunt and penetrating injury to the liver remains a difficult therapeutic problem, often resulting in massive intraperitoneal blood loss. Perihepatic liver packing and inflow occlusive techniques in combination with finger fracture exploration of injuries to allow vessel ligation are the mainstays if treatment with normal liver parenchyma. More recently fibrin glue haemostatic agents have been used to arrest traumatic haemorrhage from the liver. We report a case of the use of fibrin glue to arrest the bleeding caused by the percutaneous biopsy of a liver haemangioma.

Case Outline

A 42 year-old woman underwent percutaneous diagnostic biopsy of a liver lesion and subsequently experienced shock secondary to massive bleeding from the biopsy site. At laparotomy there was massive bleeding from the puncture site of the liver lesion. Control of haemorrhage was obtained by injecting fibrin glue down the biopsy site tract. This manoeuvre resulted in complete arrest of haemorrhage with no adverse effect.

Discussion

The use of fibrin glue as a haemostatic agent in trauma is an important adjunct to perihepatic liver packing and finger fracture exploration of injuries. It may have exceptional utility in patients with penetrating trauma to the liver by direct intraparenchymal injection. This case illustrates that fibrin glue can be used to arrest bleeding from vascular tumours such as haemangiomas. It may help to minimise bleeding for all percutaneous liver biopsies.

Introduction

Bleeding from the liver caused by both blunt and penetrating injuries is an important problem; the rich blood supply of the liver can result in massive blood loss. Tisseel (fibrin glue) is a biological haemostatic agent that forms a coagulum and seals bleeding points ¹. It is made by combining human fibrinogen with a thrombin solution containing calcium; the two components are mixed and are applied simultaneously to form the coagulum. We report a case of massive liver haemorrhage due to percutaneous liver biopsy of a liver haemangioma in which control of bleeding was obtained by intraparenchymal injection of fibrin glue.

Case Report

A 42-year-old woman presented with vague right upper quadrant abdominal pain. She was an achondroplastic dwarf with congenital tracheobronchial stenosis and asthma. She also had a history of previous emergency tracheostomy during a caesarean section for lack of airway capture. There was no past history of malignancies, liver pathology, infectious hepatitis or excess alcohol consumption. Investigation revealed a solid mass in segment VI of the liver which showed intense enhancement in the hepatic arterial phase, with rapid washout during the portal venous and delayed phases of a triple-phase scan (Figure 1). The lesion was felt to be most in keeping with a hepatoma, but the possibility of a hemangioma could not be ruled out.

Figure 1. .

CT scan showing a tumour in the right liver that was thought to be a hepatoma.

Percutaneous liver biopsy of the lesion was obtained under CT guidance with an 18-gauge needle. Almost immediately afterwards the patient developed diffuse abdominal pain associated with hypotension. She was transferred to the Emergency Department, where she underwent vigorous fluid resuscitation. She was then taken for a repeat CT scan of the abdomen, which showed massive haemoperitoneum and a vascular blush indicative of active ongoing bleeding (Figure 2).

Figure 2. .

CT scan (contrast-enhanced) after biopsy showing free blood in the abdominal cavity plus visual extravasation of intravenous contrast (↑) indicating continued bleeding from the tumour.

The patient was taken urgently to the operating room and remained haemodynamically unstable. Attempts at awake intubation over a bronchoscope failed because of severe grade 3-subglottic stenosis. Emergency tracheostomy was therefore required. After airway control was obtained laparotomy revealed four litres of clotted and fresh blood within the peritoneal cavity. The liver was packed with sponges and fluid resuscitation was continued; the patient received six units of packed red blood cells and five liters of crystalloid in total. Examination of the liver revealed ongoing bleeding from the biopsy site. The Pringle manoeuvre did not seem to reduce the amount of bleeding. Because of the soft consistency of the liver tumour, we elected not to attempt to control the haemorrhage with liver sutures and instead used Tisseel. Direct injection of 7cc Tisseel followed by ten minutes of manual compression resulted in complete arrest of the liver haemorrhage. Postoperative recovery was uneventful.

Discussion

Liver trauma can result in major blood loss. Packing of the perihepatic spaces has been well described ² as a method of controlling bleeding. Use of the finger fracture technique in hepatic trauma to expose bleeding vessels along an injury tract has been described as the treatment of choice to control bleeding in a haemodynamically stable patient ³,⁴,⁵,⁶.

Fibrin glue has often been used to stop bleeding from the raw surface of the liver ¹,². It has also been suggested that direct intraparenchymal injection of fibrin glue is an excellent means to stop bleeding ⁷. This view was subsequently questioned by Berguer and colleagues who reported two cases of severe reactions to fibrin glue, including one death related to cardiovascular collapse ⁸,⁹. Nevertheless, subsequent studies have shown this technique to be safe and effective when used in liver trauma ¹,²,¹⁰.

The use of this technique to stop bleeding from a vascular tumour such as haemangioma has not been reported previously. The incidence of spontaneous rupture of liver haemangiomas is approximately 1–4%. There are approximately 30 cases in the international literature, with a mortality of 60% ¹¹. This high mortality rate is thought to be related to the inability to gain adequate control of bleeding from these vascular tumours in a timely fashion. The surgeon is often faced with performing a liver resection to control the bleeding; because the abnormal venous and arterial architecture of these tumours does not permit successful arrest of haemorrhage by manoeuvres such as packing. It is this abnormal vascular architecture that can lead to uncontrollable bleeding when these tumours are injured or rupture spontaneously. In this case a formal right hepatectomy would have been necessary to remove the tumour if other methods did not work. Placing liver sutures through the haemangioma seemed likely to cause more bleeding. Fibrin glue injection into the biopsy site was utilized as a first attempt at controlling bleeding from this liver tumour. It could be a useful adjunct to all percutaneous liver biopsies to prevent serious bleeding.

The incidence of massive bleeding after percutaneous biopsy of liver lesions has been reported to be <1.5% ¹². A review of the world literature has shown mortality rates after percutaneous biopsy ranging from 0.009% to 0.017% ¹³. Fine needle aspiration biopsy is safer than TruCut® liver biopsy ¹⁴. A prospective study in 72 high-risk patients that used biopsy tract embolisation with gelatin particles and thrombin achieved a serious bleeding complication rate of 2.8% ¹⁵. Based on our observation with this one patient, we feel that fibrin glue injected down the tract of a penetrating injury could be a useful adjunct in liver trauma to arrest hemorrhage; especially in an unstable patient who is not a candidate for finger fracture exploration of the injury tract. Further studies with fibrin glue, are needed to verify its safety.