Hepatic Compartment Syndrome Following Percutaneous Cholecystostomy: A Case Report

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Objective: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.Design:Case report.Setting:Surgical ICU of a university teaching hospital.Patient: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.Interventions: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.Measurements and Main Results: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.Conclusions: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.

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