Alcohol Abuse and Alcoholic Liver Cirrhosis Leading to Spontaneous Muscle Hematoma: An Event Fraught with Danger

Abstract

Alcohol abuse is associated with both potentiating and antagonizing hemostatic states. Liver cirrhosis is an independent causal factor for many bleeding complications. The long-term effects of alcohol abuse coupled with advanced liver cirrhosis are additive in favor of bleeding. We report the case of a patient with a history of alcohol abuse who presented with liver cirrhosis and nontraumatic muscle hematoma diagnosed as a spontaneous hematoma of the gastrocnemius muscle. He was managed conservatively with infusions of fresh frozen plasma and platelets, which resulted in resolution of the hematoma. The pathogenesis of ‘spontaneous' muscle hematoma remains anecdotal, but since it is reported in patients on anticoagulant therapy or with hemostatic disorders, it is hypothetically related to severely deranged coagulation. Here we review the relevant literature pertaining to the pathogenesis, presentation and treatment options available for treating this often fatal complication of bleeding diatheses.

Aggressive Surgical Management of Spontaneous Intramuscular Haematomas in Patients with Cirrhosis is an Important Therapeutic Option

“…This particular clinical entity has been predominantly the subject of sporadic case reports or case series. Apart from one small case series [5], the majority of the cases were summarised in a published review in 2015 [6]. Hence the most recent case report from Mongelli et al published recently in this journal [7], now becomes the 25 th case.…”

“…So why are the clinical outcomes generally so poor? Although not all of the case reports include data on the magnitude of the severity of the associated liver disease where the data is available it seems that a number of the patients 9/25 (36%) had Childs C cirrhosis and/or a MELD (Model for End-stage Liver Disease) score of 20 or higher [5,6]. Hence it is possible that the actual stage of the underlying liver disease is a risk factor for an adverse outcome along with perturbation of the coagulation indices [8].…”

“…Hence it is possible that the actual stage of the underlying liver disease is a risk factor for an adverse outcome along with perturbation of the coagulation indices [8]. As most of the patients had a diagnosis of alcoholic cirrhosis in 21/25 (84%) of cases, this alone may also be a risk factor, particularly if the alcohol ingestion was occurring right up to or close to the time of onset of the spontaneous haemorrhage [6]. Also, when it comes to deploying trans arterial embolization (TAE) for spontaneous intramuscular haemorrhage in other patient cohorts, there is some evidence that the greater the magnitude of the haemorrhage, the less likely that TAE will be successful [9].…”

Octreotide as a bridge to definitive surgery in a patient with cirrhosis and a large spontaneous abdominal wall haematoma

“…[1][2][3] To our knowledge, octreotide has not been used as a haemostatic agent in this setting. The overall survival rate was 34% (14/41 cases), with very poor survival rates among Child-Pugh C cases (14%).…”

“…Although no randomised trial data were available, the outcome of patients undergoing interventional management strategies (45% survival), including transcatheter arterial embolisation, haematoma evacuation or fasciotomy was better than those managed conservatively (24% survival). [1][2][3] To our knowledge, octreotide has not been used as a haemostatic agent in this setting. We hypothesise that octreotide may have facilitated haemostasis through a reduction in portal flow through known porto-systemic collateral pathways to the anterior abdominal wall and its effects on local vasoconstriction.…”