Massive hepatic haematoma in patient on haemodialysis
Hematoma hepático gigante en un paciente en hemodiálisis
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Peces, Vega Cabrera, I. Campos, C. Peces" "autores" => array:4 [ 0 => array:4 [ "Iniciales" => "R." "apellidos" => "Peces" "email" => array:1 [ 0 => "cpeces@varnet.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "affa" ] ] ] 1 => array:3 [ "nombre" => "Vega" "apellidos" => "Cabrera" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "affa" ] ] ] 2 => array:3 [ "Iniciales" => "I." "apellidos" => "Campos" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "affa" ] ] ] 3 => array:3 [ "Iniciales" => "C." "apellidos" => "Peces" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "affb" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Servicio de Nefrología, Hospital Universitario La Paz, Madrid, Madrid, España, " "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "affa" ] 1 => array:3 [ "entidad" => "Area de Tecnología de la Información, SESCAM, Toledo, Toledo, España, " "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "affb" ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Hematoma hepático gigante en un paciente en hemodiálisis" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig1" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "figura" => array:1 [ 0 => array:4 [ "imagen" => "19018078_f1_p280.jpg" "Alto" => 281 "Ancho" => 260 "Tamanyo" => 19086 ] ] ] ] "textoCompleto" => "<p class="elsevierStylePara">Dear Editor:</p><p class="elsevierStylePara">Patients on periodic HD have an elevated risk of spontaneous haemorrhages or haemorrhages caused by minimal trauma to the retroperitoneal, renal, pericardial, mediastinic and subdural areas. Multiple factors affect predisposition to bleeding, including platelet dysfunction, antiplatelet agents and anticoagulants.<span class="elsevierStyleSup">1,2</span> The development of a subcapsular hepatic haematoma is an exceptional complication that can occur spontaneously or with minimal closed trauma.<span class="elsevierStyleSup">3,4</span> We present a patient aged 77 years who in 2003 was diagnosed with chronic kidney disease second to myeloma kidney (IgG Kappa). Treatment with melfalan/prednisone decreased the circulating paraprotein and improved the medullar affectation. In February 2004, the patient began HD. During the last two years, the patient received two cycles of melfalan/prednisone, and later, bortezomib (Velcade<span class="elsevierStyleSup">®</span>). He remained stable, with the disease under control and without anaemia with EPO. From April to July 2006, he received conjugated oestrogen (Equin<span class="elsevierStyleSup">®</span>) (20mg/day) for uraemic thrombopathy. Lately, the patient has been taking aspirin as an anti-platelet agent. On 7 August 2006, eight hours after finishing the HD session, he experienced dizziness and fell, striking his right hypochondrium, and lost consciousness for several minutes. When he was admitted to the hospital he was conscious and aware of his surroundings; he complained of pain in his right scapula. Blood pressure was 55/35, cardiac frequency 72l/min and he showed sinus rhythm. Analytical tests showed: haematocrit 19%, haemoglobin 6.9g/dl, 300,000 platelets/mm3, 10,000 leukocytes/mm<span class="elsevierStyleSup">3</span> with the normal formula, PT 82%, INR 1.2 and fibrinogen 520mg/dl. Other data: Na 139mmol/l, K 6.7mmol/l, HCO3 22mmol/l, urea 84mg/dl, Cr 7.5mg/dl, GGT 727UI/l, GOT 127UI/l, GPT 167UI/l, LDH 372UI/l and total bilirubin 0.4mg/dl. A thoracic-abdominal CT with contrast revealed a subcapsular hepatic haematoma measuring 10 x 7 x 20cm in the right lobe; the organ was displaced, but without underlying hepatic lesions (figure 1). The kidneys were atrophic and there was a moderate amount of free liquid (blood) in the pouch of Douglas. To reverse the hypovolaemia, we administered isotonic saline and blood transfusions (four packs of red blood cells) and gum for the hyperpotasaemia. Six hours after being admitted, his haemodynamics were stable and he underwent an HD session without heparin. In the following 48 hours he remained at rest and under observation with frequent haematological checks.Haemoglobin levels remained stable. Local discomfort required mild analgesics.Over the following days, HD was performed under close monitoring and without heparin. Eight days after admission, during a CTexam, the haematoma had not increased in size and remained within the subcapsular area.The patient was referred to his original unit and follow-up by a series of CTs showed the slow, progressive reabsorption of the haematoma over eight weeks, with no need for surgery.</p><p class="elsevierStylePara">The likely causes that would favour bleeding, in addition to the uraemia, could include the myeloma itself, the administration of oestrogens, use of heparin during HD, the anti-platelet agent, and lastly, the closed local trauma. Although the CT showed no sign of underlying hepatic lesions (adenoma, haemangioma or peliosis) the patient could suffer from lesions arising from hepatic peliosis that were undetected by the CT.<span class="elsevierStyleSup">4,5</span> Hepatic peliosis , which is characterised by cystic blood-filled spaces in the sinusoids, is associated with the administration of androgenic-anabolic and other steroids, oral contraceptives and synthetic oestrogens. Its complications can include ruptured liver and spontaneous hepatic haematoma.<span class="elsevierStyleSup">6-12</span> In this case, both the myeloma and the oestrogens could have favoured the development of hepatic peliosis,<span class="elsevierStyleSup">8,10</span> making the liver more susceptible to spontaneous rupture or rupture from closed trauma.<span class="elsevierStyleSup">3</span> Many hepatic haematomas that are haemodynamically stable are given conservative treatment without surgical intervention and have a success rate of more than 80%.<span class="elsevierStyleSup">13,14</span> The only determining factor for it to be treated without surgical intervention is haemodynamic stability. In our patient, once his haemodynamics were stable, conservative treatment consisting of rest, transfusions, close monitoring and HD without heparin permitted favourable evolution and the resolution of the haematoma in two months.</p><p class="elsevierStylePara">To sum up, the development of a subcapsular hepatic haematoma in HD is a rare complication which, by producing a severe haemorrhage and shock, places the patient’s life at risk and is a challenging situation. Conservative treatment with no surgical intervention is an option that permits recovery without problems. As far as we know, this is the first case of a patient undergoing periodic HD who has presented this complication.</p><p class="elsevierStylePara"><a href="grande/19018078_f1_p280.jpg" class="elsevierStyleCrossRefs"><img src="19018078_f1_p280.jpg"></img></a></p><p class="elsevierStylePara">Figure 1. </p>" "pdfFichero" => "P-E-S-A190-EN.pdf" "tienePdf" => true "multimedia" => array:1 [ 0 => array:7 [ "identificador" => "fig1" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "figura" => array:1 [ 0 => array:4 [ "imagen" => "19018078_f1_p280.jpg" "Alto" => 281 "Ancho" => 260 "Tamanyo" => 19086 ] ] ] ] "bibliografia" => array:2 [ "titulo" => "Bibliography" "seccion" => array:1 [ 0 => array:1 [ "bibliografiaReferencia" => array:14 [ 0 => array:3 [ "identificador" => "bib1" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Sohal AS, Gangji AS, Crowther MA, Treleaven D. 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| 2024 July | 39 | 33 | 72 |
| 2024 June | 60 | 36 | 96 |
| 2024 May | 64 | 28 | 92 |
| 2024 April | 58 | 29 | 87 |
| 2024 March | 39 | 25 | 64 |
| 2024 February | 39 | 37 | 76 |
| 2024 January | 43 | 31 | 74 |
| 2023 December | 55 | 23 | 78 |
| 2023 November | 58 | 30 | 88 |
| 2023 October | 71 | 30 | 101 |
| 2023 September | 58 | 29 | 87 |
| 2023 August | 67 | 27 | 94 |
| 2023 July | 89 | 23 | 112 |
| 2023 June | 94 | 19 | 113 |
| 2023 May | 117 | 29 | 146 |
| 2023 April | 112 | 23 | 135 |
| 2023 March | 94 | 17 | 111 |
| 2023 February | 56 | 28 | 84 |
| 2023 January | 55 | 35 | 90 |
| 2022 December | 45 | 26 | 71 |
| 2022 November | 40 | 30 | 70 |
| 2022 October | 48 | 38 | 86 |
| 2022 September | 44 | 22 | 66 |
| 2022 August | 51 | 44 | 95 |
| 2022 July | 44 | 39 | 83 |
| 2022 June | 30 | 21 | 51 |
| 2022 May | 59 | 28 | 87 |
| 2022 April | 52 | 50 | 102 |
| 2022 March | 62 | 32 | 94 |
| 2022 February | 60 | 41 | 101 |
| 2022 January | 57 | 25 | 82 |
| 2021 December | 43 | 41 | 84 |
| 2021 November | 44 | 26 | 70 |
| 2021 October | 46 | 40 | 86 |
| 2021 September | 52 | 40 | 92 |
| 2021 August | 41 | 24 | 65 |
| 2021 July | 40 | 34 | 74 |
| 2021 June | 27 | 19 | 46 |
| 2021 May | 48 | 26 | 74 |
| 2021 April | 74 | 44 | 118 |
| 2021 March | 68 | 11 | 79 |
| 2021 February | 60 | 16 | 76 |
| 2021 January | 43 | 13 | 56 |
| 2020 December | 29 | 4 | 33 |
| 2020 November | 30 | 12 | 42 |
| 2020 October | 17 | 16 | 33 |
| 2020 September | 28 | 9 | 37 |
| 2020 August | 36 | 8 | 44 |
| 2020 July | 41 | 11 | 52 |
| 2020 June | 18 | 13 | 31 |
| 2020 May | 30 | 16 | 46 |
| 2020 April | 32 | 11 | 43 |
| 2020 March | 35 | 7 | 42 |
| 2020 February | 40 | 17 | 57 |
| 2020 January | 50 | 19 | 69 |
| 2019 December | 34 | 28 | 62 |
| 2019 November | 47 | 11 | 58 |
| 2019 October | 21 | 5 | 26 |
| 2019 September | 26 | 18 | 44 |
| 2019 August | 59 | 9 | 68 |
| 2019 July | 53 | 21 | 74 |
| 2019 June | 38 | 7 | 45 |
| 2019 May | 28 | 5 | 33 |
| 2019 April | 74 | 31 | 105 |
| 2019 March | 31 | 9 | 40 |
| 2019 February | 16 | 14 | 30 |
| 2019 January | 32 | 18 | 50 |
| 2018 December | 34 | 25 | 59 |
| 2018 November | 61 | 9 | 70 |
| 2018 October | 55 | 7 | 62 |
| 2018 September | 38 | 15 | 53 |
| 2018 August | 31 | 9 | 40 |
| 2018 July | 22 | 12 | 34 |
| 2018 June | 19 | 8 | 27 |
| 2018 May | 37 | 10 | 47 |
| 2018 April | 29 | 5 | 34 |
| 2018 March | 28 | 8 | 36 |
| 2018 February | 42 | 6 | 48 |
| 2018 January | 46 | 13 | 59 |
| 2017 December | 32 | 6 | 38 |
| 2017 November | 27 | 3 | 30 |
| 2017 October | 25 | 7 | 32 |
| 2017 September | 33 | 7 | 40 |
| 2017 August | 37 | 9 | 46 |
| 2017 July | 33 | 13 | 46 |
| 2017 June | 32 | 26 | 58 |
| 2017 May | 43 | 10 | 53 |
| 2017 April | 37 | 6 | 43 |
| 2017 March | 25 | 2 | 27 |
| 2017 February | 20 | 5 | 25 |
| 2017 January | 24 | 7 | 31 |
| 2016 December | 72 | 7 | 79 |
| 2016 November | 73 | 5 | 78 |
| 2016 October | 77 | 7 | 84 |
| 2016 September | 106 | 1 | 107 |
| 2016 August | 123 | 3 | 126 |
| 2016 July | 129 | 6 | 135 |
| 2016 June | 111 | 0 | 111 |
| 2016 May | 102 | 0 | 102 |
| 2016 April | 77 | 0 | 77 |
| 2016 March | 71 | 0 | 71 |
| 2016 February | 70 | 0 | 70 |
| 2016 January | 83 | 0 | 83 |
| 2015 December | 85 | 0 | 85 |
| 2015 November | 75 | 0 | 75 |
| 2015 October | 60 | 0 | 60 |
| 2015 September | 50 | 0 | 50 |
| 2015 August | 52 | 0 | 52 |
| 2015 July | 40 | 0 | 40 |
| 2015 June | 35 | 0 | 35 |
| 2015 May | 33 | 0 | 33 |
| 2015 April | 5 | 0 | 5 |
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