Introduction: Hepatic Subcapsular Hematoma (HSH) is an infrequent condition most associated with HELLP syndrome, as an uncommon complication of ERCP and as a result of coagulopathies or malignancies. In this case report we present a 72-year-old woman with metastatic cancer who died after a spontaneous rupture of a HSH.
Case Description/Methods: A 72-year-old woman with a history of metastatic lung adenocarcinoma presented to the hospital for lower extremity weakness. She was currently undergoing immunotherapy with pembrolizumab. On admission she no complaint and abdominal exam was normal. No imaging was done of the abdomen, but prior MRI and CT of the abdomen had noted small right lobe lesions within the liver. Previous ultrasound of the liver had also shown 3.5cm posterior right lobe mass. Initial labs showed a PT/INR of 14.6 and 1.3 respectively. Alkaline phosphatase was 237, AST was 36 and ALT was 28, and platelet of 290.
Her stay was uneventful until day 7 when she started to develop thrombocytopenia with a platelet count of 24, PT/INR of 16.3/1.4 respectively, and fibrinogen of 68. The next day LDH was 2,500 and she started to develop a leukocytosis. On day 10 a rapid response was called for acute right upper quadrant pain. Initial evaluation showed sinus tachycardia but a soft and non-tender abdomen. She became less responsive, so she was taken to the CT scanner which showed a large subcapsular hemorrhage compressing both her liver and her aorta against her spine. (Fig. 1)
She was intubated and taken to the MICU where she was started on pressor support and the massive transfusion protocol was activated. Surgery came and evaluated her but felt that given the size of her hemorrhage an emergent laparotomy would be fatal. She ultimately was changed to DNR/DNI by family and died.
Discussion: HSH ruptures are cited as complication of tumors, HELLP syndrome, and as a rare complication of ERCP. Initial symptoms almost always include abdominal pain but can also include anemia and shock. When shock is present in-hospital mortality rate can be as high as 23%. The mainstay of treatment in unstable patients is surgical resection or trans-arterial embolization.
Even if surgical intervention is initially successful most patients die within a year due to either liver failure or hemorrhagic recurrence. In our patient her age and underlying cancer made surgical intervention almost certainly fatal. This case reinforces the current literature around HSH rupture and serves to demonstrate the severity of this condition.
