Marcaire Fanny, Malavieille François, Pichot-Delahaye Virginie, Floccard Bernard, Rimmelé Thomas
1Department of Anesthesiology and Critical Care Medicine, Edouard Herriot Hospital, Hospices Civils de Lyon, Lyon, France.2Department of Surgery, Edouard Herriot Hospital, Hospices Civils de Lyon, Lyon, France.
Crit Care Med. 2016 Mar;44(3):e174-7. doi: 10.1097/CCM.0000000000001403.
To describe a case of hepatic subcapsular hematoma causing an acute Budd-Chiari-like syndrome, leading to hepatic compartment syndrome, which combines compression of intrahepatic vessels on CT, acute liver failure, and refractory shock.
Case report.
Surgical ICU of a university teaching hospital.
Single case: A 64-year-old man hospitalized for 1 month in the ICU after multiple complications following bypass surgery, under anticoagulation after a recent aortic valve replacement and without a medical history of hepatic disease, underwent a percutaneous cholecystostomy for acute calculous cholecystitis. Fifteen days later, he presented with acute anemia, abdominal tenderness, severe hepatic cytolysis, metabolic acidosis, and hemodynamic dysfunction. CT showed a voluminous subcapsular hematoma compressing the hepatic parenchyma, which appeared ischemic with a flattened right lobar portal vein and vena cava without any visible active bleeding.
Arteriography and evacuation of the hematoma under ultrasound guidance (while managing hemodynamic dysfunction) were preferred to surgery given the patient's instability and surgical history.
Evidence of vessels and parenchymal compression with no source of bleeding was found despite removal of the cholecystostomy catheter. Two right sectorial inferior hepatic arteries were embolized. Hematoma was punctured to relieve pressure on hepatic parenchyma, retrieving 300 mL of blood. Unfortunately, liver failure worsened dramatically while patient developed refractory shock and died.
Hepatic compartment syndrome must be suspected when acute liver failure occurs in patients with subcapsular hematoma. Only early management may avoid a fatal outcome or the need for an emergency liver transplantation.
描述一例肝包膜下血肿导致急性布加综合征样综合征，进而引发肝间隔综合征的病例，该综合征在CT上表现为肝内血管受压、急性肝衰竭和难治性休克。
病例报告。
一所大学教学医院的外科重症监护病房。
单例：一名64岁男性，在搭桥手术后出现多种并发症，在最近进行主动脉瓣置换术后接受抗凝治疗，无肝脏疾病病史，因急性结石性胆囊炎接受了经皮胆囊造瘘术，在重症监护病房住院1个月。15天后，他出现急性贫血、腹部压痛、严重肝细胞溶解、代谢性酸中毒和血流动力学功能障碍。CT显示巨大的包膜下血肿压迫肝实质，肝实质呈缺血表现，右叶门静脉和腔静脉变扁，未见明显活动性出血。
鉴于患者病情不稳定及手术史，在超声引导下进行动脉造影和血肿清除术（同时处理血流动力学功能障碍）比手术更可取。
尽管拔除了胆囊造瘘导管，但仍发现有血管和实质受压且无出血源。栓塞了两支右叶肝下动脉。穿刺血肿以减轻对肝实质的压力，抽出300毫升血液。不幸的是，肝功能衰竭急剧恶化，患者出现难治性休克并死亡。
当包膜下血肿患者发生急性肝衰竭时，必须怀疑肝间隔综合征。只有早期处理才能避免致命后果或紧急肝移植的需要。
