Bleeding hepatico-cutaneous fistula: Unusual complication of the percutaneous liver biopsy

Introduction. Arteriovenous fistula is one of the complications that can occur during percutaneous liver biopsy. Hepatic arterio-venous fistula with chronic bleeding from the puncture site on the skin is extremly rare complication following percutaneous liver biopsy. Case report. The case represents a 35-year-old woman with secondary anemia caused by chronic bleeding at the site of a granuloma caused by a previous liver biopsy done 7 years ago. The patient was examined and treated for several years due to anemic syndrome. The pathological communication between the right hepatic vein, the anterior sectional branch of the portal vein and the posterior arterial sectional branch was detected on a CT scan, and proven by fistulography. Due to the failed embolization, a laparotomy was performed, where a tumor mass was found in the VI and VII segment of the liver, which communicates with the skin. Tumor mass was removed by atypical resection of VI and VII liver segments. Due to hemorrhage, re-exploration was performed, where bleeding was found from the surface of the resected liver parenchyma. Two weeks after the last operation, the patient was released for home treatment. Conclusion. Although percutaneous liver biopsy is a safe procedure, the complication in the form of bleeding occurs in less than 25% of cases and with spontaneous cessation. In our presentation, there was a complicated intrahepatic arteriovenous-portal fistula with the formation of communication with the puncture site on the skin. This is the first case of complications of this type after percutaneous liver biopsy.

Massive hemorrhage after percutaneous liver biopsy in a pediatric patient with graft-versus-host disease; a successful angiographic embolization

Most cases of bleeding that develop after percutaneous liver biopsies can be managed with follow-up and supportive treatment. In life-threatening situations, however, open surgery or minimally invasive methods are required. This case report describes the clinical course of an 11-year-old patient with a diagnosis of Wiskott-Aldrich syndrome who experienced a major hemorrhage following a percutaneous liver biopsy. Clinical findings, imaging, interventions, and results were evaluated. Allogeneic hematopoietic stem cell transplantation was performed without any problem. The patient's bilirubin level started to increase on the 20th day after transplantation. Profuse watery diarrhea started on the 24th day. Graft-versus-host disease of the gastrointestinal tract and liver was considered as his diarrhea continued to the 29th day. An ultrasound-guided Tru-cut® liver biopsy (Merit medical, South Jordan, UT, USA) was performed with an 18-gauge needle on the 52nd day after transplantation. In the fourth hour after the procedure, the general condition of the patient started to deteriorate. Active bleeding was detected in the patient with computed tomography, and he was hypotensive and tachycardic. The patient was urgently transferred to the angiography unit and a successful angiographic embolization was performed. Angiographic embolization is an intervention with high success rates in cases of bleeding where the patient is hemodynamically stable. However, it can also be successfully applied in selected patients who are hemodynamically unstable.

Effects of Different Recovery Positions on the Postpercutaneous Liver Biopsy Complications: A Metaanalysis

Objective: We aim to evaluate the effects of different recovery positions on the adverse events and the patient acceptability in those who underwent percutaneous liver biopsy (PLB).Methods: A literature search was conducted in the Cochrane Library, Embase, Scopus, PubMed, CNKI, Sinomed, and Wanfang databases. The time for the article extraction was until July 2020. The articles were screened by two independent researchers, together with the bias risk evaluation and data extraction. The RevMan 5.4 software was utilized for the metaanalysis.Results: Finally, two articles involving 180 subjects were eligible for this study. Metaanalysis showed that at T0, the alternation between right-side and combined position (CRP) would induce an elevation of post-PLB pain compared with the dorsal/supine position (SRP) [WMD = −2.00, 95% CI (−3.54, −0.47), p = 0.01]. There were no statistical differences in the postoperative pain among the CRP, SRP, and right-side position (RRP). The patient acceptability of SRP and RRP was higher than that of the CRP. Finally, two eligible studies were included, which showed no incidence of pneumothorax and abdominal bleeding.Conclusions: CRP would induce post-PLB pain at T0. SRP was the most acceptable position for the cases that underwent PLB. There were no statistical differences in the incidence of pneumothorax and abdominal bleeding.Systematic Review Registration:https://www.crd.york.ac.uk/PROSPERO, identifier: CRD42020196633.

Value and risk of percutaneous liver biopsy in patients with cirrhosis and clinical suspicion of autoimmune hepatitis

ObjectiveThe decision regarding whether to perform a liver biopsy in patients with cirrhosis and clinically suspected autoimmune hepatitis (AIH) remains a challenge. This study aimed to assess the utility and complications of percutaneous liver biopsy in cirrhosis for differentiating AIH from other liver conditions.MethodsA clinicopathological database of patients undergoing percutaneous liver biopsies for suspected AIH (unexplained hepatitis with elevated γ-globulin and autoantibody seropositivity) was reviewed to identify patients presenting with cirrhosis. Biopsy slides were reviewed by an experienced hepatopathologist who was blinded to clinical data.ResultsIn 207 patients who underwent liver biopsy for suspected AIH, 59 patients (mean age: 59.0±12.0 years, 83.1% female) had clinically diagnosis of cirrhosis. Mean Child-Turcotte-Pugh score was 6.6±1.6, and 44% of patients had a Child-Turcotte-Pugh score≥7. According to the revised International AIH Group (IAIHG) criteria, histology assessment combined with clinical information facilitated a diagnosis of AIH or overlap syndrome of AIH and primary biliary cholangitis (PBC) in 81.4% of cases. Liver biopsy identified other aetiologies, including PBC (n=2), non-alcoholic steatohepatitis (n=6) and cryptogenic cirrhosis (n=3). A reliable diagnosis of AIH could be made using histological category of the simplified criteria in 69.2% and 81.8% of cases using IAIHG scores before biopsy of <10 and 10–15, respectively. Three patients with cirrhosis (5.1%) experienced bleeding following biopsy, but none of 148 patients with non-cirrhosis had bleeding complication (p=0.022).ConclusionLiver biopsy provides important diagnostic information for the management of patients with cirrhosis and suspected AIH, but the procedure is associated with significant risk.

Intrahepatic Hematoma and Haemobilia After Percutaneous Liver Biopsy: A Clinical Case Report

Summary Assessing the severity of liver disease and predict the response to treatment in clinical practice requires the determination of the degree of inflammation progression and liver fibrosis. Percutaneous liver biopsy is the gold standard for grading and staging liver diseases. Complications are more common in the presence of vascular liver lesions, dilation of the bile ducts, ascites, or whether examination has been performed by less experienced physicians. Bleeding after liver biopsy is considered the most common cause of severe complications. Bleeding usually presents as a subcapsular or parenchymal hematoma, free intraperitoneal hemorrhage, hemobilia, or, rarely, hemothorax. The rarest of hemorrhagic complications is hemobilia, a term used to describe bleeding in the bile ducts. Hemobilia is usually suspected when there is a drop in hemoglobin after the procedure, pain in the upper right quadrant of the abdomen, hyperbilirubinemia, and unexplained gastrointestinal bleeding. The clinical manifestations range from chronic anemia to rapid, massive bleeding with hematemesis and/or melena.