Subcapsular hematoma resulting in hepatic ischemia as a complication of necrotizing pancreatitis

Abstract

This report presents a case of necrotizing pancreatitis resulting in a large hepatic subcapsular hematoma that led to development of hepatic ischemia and early stages of liver failure. Following surgical decompression, liver function dramatically improved, but large areas of peripheral hepatic infarction had developed. This case demonstrates the risks of a rapidly expanding hepatic subcapsular hematoma, emphasizes the importance of recognizing and aggressively treating active bleeding, and cautions against administering anticoagulation and tissue-plasminogen activator in this clinical scenario.

Keywords: Hepatic hematoma; Hepatic infarct; Necrotizing pancreatitis.

Fig. 1

Axial portal venous phase CT image obtained at the outside hospital prior to transfer shows normal hepatic parenchymal enhancement and no subcapsular hematoma.

Fig. 2

(A) Axial arterial phase CT and (B) fluoroscopic angiographic images 2 days after transfer demonstrate a large perihepatic subcapsular hematoma (arrow) resulting in marked mass effect upon the hepatic parenchyma and medial displacement of the right lobe of the liver. (C) Axial and coronal (D) arterial phase CT images demonstrate a focus of active arterial extravasation at the periphery of the liver within the hematoma (arrow, C) and active arterial extravasation (arrowhead) in the gallbladder fossa, which was confirmed at angiography (E).

Fig. 3

Multiphase CT examination performed 4 days after transfer and 2 days after embolization. Precontrast (A), hepatic arterial (B), and portal venous axial images through the liver (C) demonstrate peripheral-predominant, wedge-shaped hypoattenuating right hepatic regions that do not enhance significantly. Coronal portal venous phase CT image (D) demonstrates the marked mass effect of the perihepatic and subcapsular hematoma resulting in medialization of the liver parenchyma and compression of the right portal vein (arrow).

Fig. 4

Coronal (A) and axial (B) contrast-enhanced CT images obtained 32 days after subcapsular hematoma evacuation demonstrate regions of persistent wedge-shaped nonenhancement in the periphery of the right hepatic lobe, consistent with peripheral hepatic infarcts. Note that the caliber of the right portal vein has been restored to normal (arrows) following hematoma evacuation and resolution of mass effect upon the liver.