Percutaneous Liver Biopsy after Living Donor Liver Transplantation Resulting in Fulminant Hepatic Failure: The First Reported Case of Hepatic Compartment Syndrome

Abstract

A 28-year-old female who underwent live donor liver transplantation 3 years prior presented after percutaneous liver biopsy with abdominal and shoulder pain, nausea, vomiting, and elevated liver enzymes. Computed tomography (CT) showed an intrahepatic and subcapsular hematoma. There was a progressive increase in liver enzymes, bilirubin, and INR and a decline in hemoglobin. Subsequent CT imaging revealed flattening of the portal vein consistent with compression by the enlarging hematoma. Liver failure ensued and the patient required urgent retransplantation. The explant demonstrated ischemic necrosis of greater than 90% of the liver parenchyma. We report this case of “Hepatic Compartment Syndrome” leading to fulminant hepatic failure.

Acute liver failure secondary to hepatic compartment syndrome: case report and literature review

“…[1] Similarly, it is likely that hepatic parenchymal pressure, hepatic necrosis, and hypovolemia worked in concert to cause hepatic injury in our case. [2] Hence, we believe this syndrome could be termed as "Hepatic Compartment Syndrome". In summary, acute liver failure in patients with rapidly expanding intrahepatic hematoma may be attributed to climbing intrahepatic pressure and hepatic necrosis.…”

“…This "Hepatic Compartment Syndrome" led to ischemic hepatic failure. [2] Hence, she underwent percutaneous drainage and fortunately, the liver enzyme decreased rapidly and thereafter recovery was unevenly. Then patient was discharged on day 47.…”

Early Spontaneous Graft Intra- and Perihepatic Hematoma after Liver Transplantation

“…It may present as intrahepatic, subcapsular or both and may develop spontaneously or subsequently to parenchimal injuries, either intraoperative (parenchimal laceration by compression) (5,6) or afterpercutaneous transhepatic invasive procedures, such as endoscopic retrograde cholangiopancreatography (7) or liver biopsy (8). Likewise, it may occur either after full-sized or partial-liver graft transplantation (1,2,3,4).…”

“…Transplanted livers may be more sensitive to microtrauma and to blood flow compromise than the native liver as a consequence of loss of vascular autoregulation and of collateral flow (8). Therefore, the liver graft must be handled with special care to prevent potential mechanical injuries, either during organ procurement or transplantation procedure (5,6).…”

“…In our reported case, it is likely that perihepatic large hematomas behaved like a "perihepatic packing" with compressive effect on the liver but without vascular intrahepatic compromise or thrombosis. On the contrary, the "liver compartment syndrome" (8) leads to acute hepatic failure, usually requiring retransplantation.…”