Patho-mechanical comparative morpho-characterization of contre-coup injuries of liver by cadaveric experimental simulation for medico-legal and forensic implications

BACKGROUND

Liver is the most common organ to get injured in cases of blunt force trauma to the abdomen (BFTA). It is the 2nd commonest organ after brain to sustain injuries out of all the trauma related fatalities. However, the literature about contre-coup injuries to the liver due to BFTA is scarce in-spite of the high mortality rates seen out of injury to this particular organ.

PURPOSE

The authors intended to systematize the characteristic morphogenesis of the contre-coup injuries of the liver on the basis of the patho-mechanics involved in various types of BFTA.

METHODOLOGY

One hundred and sixty three cases of BFTA were identified, and interpretation was attempted for the contre-coup rupture of the liver seen in twenty out of all the trauma related fatalities that presented for post-mortem examination during the study period. However, the mechanics of the pattern of the rupture injuries to the liver were indiscernible. This motivated the authors to conduct the comparative characterization of injuries to the liver by experimental simulation of BFTA after necessary permission via inflicting pre-calculated forces on unclaimed cadavers.

RESULTS

The patterns of contre-coup rupture/s of liver were established in all the twenty-eight out of one sixty-three cases of BFTA. The rupture depicted patterns of injury in the situations of - 1) strong hits with a limited surface trauma, 2) very strong hits with a generalized surface trauma, 3) and collision with a solid surface resulting due to fall onto the side of the abdomen. The causative mechanism discerned was deformation of the liver, followed by its parenchymal rupture due to the shear and strain types of force/s consequent upon tissue compression. The minimum force and energy of impact required for the liver to rupture was estimated to be 2000 N and 141.5 J.

CONCLUSION

This series of the simulation experiments revealed two variants of liver rupture in the contre-coup impact zone. The pattern of injury was maintained in cases, those studied at post-mortem examinations, but the relief ruptures were found to vary depending upon the overall mechanics of the traumatic forces involved in the simulation experiments performed on the cadavers. The anti-shock ruptures were formed during shock trauma, and shockproof ruptures were not seen in cases of underlying compressive forces. The morphogenetic characterization of the relief rupture surface of the liver was also delineated in relation to its surface orientation to the spine on the basis of the terms "large" and "very large" depicting the quantum of force/s delivered out of an impact or blow.

Hypertensive disorders in pregnancy complicated by liver rupture or hematoma: a systematic review of 391 reported cases

Background

Spontaneous liver rupture in pregnancy is often unrecognized, highly lethal, and not completely understood. The goal was to summarize and define the etiology, risk factors, clinical presentation, appropriate diagnostic methods, and therapeutic options for spontaneous hepatic rupture during pregnancy/puerperium (SHRP) complicated by the hypertensive disorder.

Methods

Literature search of all full-text articles included PubMed (1946–2021), PubMed Central (1900–2021), and Google Scholar. Case reports of a spontaneous hepatic rupture or liver hematoma during pregnancy or puerperium as a complication of hypertensive disorders (preeclampsia, eclampsia, HELLP syndrome) were searched. There was no restriction of language to collect the cases. Additional cases were identified by reviewing references of retrieved studies. PRISMA guidelines for the data extraction and quality assessment were applied.

Results

Three hundred and ninety-one cases were collected. The median maternal age was 31 (range 17–48) years; 36.6% were nulliparous. Most (83.4%) occurred in the third trimester. Maternal and fetal mortality was 22.1% and 37.2%, respectively. Maternal and fetal mortality was significantly higher 1) before the year 1990, 2) with maternal hemodynamic instability, and 3) eclampsia. The most important risk factors for SHRP were preeclampsia and HELLP syndrome. Most women had right lobe affected (70.9%), followed by both lobes in 22.1% and left lobe in 6.9%. The most common surgical procedure was liver packing. Liver transplantation was performed in 4.7% with 100% survival. Maternal mortality with liver embolization was 3.0%. Higher gestational age increases fetal survival.

Conclusion

The diagnosis and treatment of SHRP are often delayed, leading to high maternal and fetal mortality. SHRP should be excluded in hemodynamically unstable patients with preeclampsia/eclampsia or HELLP syndrome and right upper abdominal pain. Liver embolization and liver transplantation contribute to maternal survival. Maternal and fetal mortality was significantly higher before the year 1990. Hemodynamic instability, preeclampsia, and eclampsia have a significant negative influence on maternal survival.

Level of evidence

Level V

Supplementary Information

The online version contains supplementary material available at 10.1186/s13017-022-00444-w.

Spontaneous liver rupture following SARS-CoV-2 infection in late pregnancy: A case report

BACKGROUND

Coronavirus disease-2019 (COVID-19) caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is characterized by systemic inflammatory response syndrome and vasculopathy. SARS-CoV-2 associated mortality ranges from 2% to 6%. Liver dysfunction was observed in 14%-53% of COVID-19 cases, especially in moderate severe cases. However, no cases of spontaneous hepatic rupture in pregnant women with SARS-CoV-2 have been reported.

CASE SUMMARY

A 32-year-old pregnant patient (gestational age: 32 wk + 4 d) without any remarkable medical history or long-term medication presented with epigastralgia. Infectious, non-infectious, and pregnancy-related hepatopathies were excluded. Sudden onset of right subcostal pain with D-dimer and liver enzyme elevation was followed by shock with thrombocytopenia. While performing an emergency cesarean section, hemoperitoneum was observed, and the patient delivered a stillbirth. A 6-cm liver rupture at the edges of segments V and VI had occurred, which was sutured and drained. SARS-CoV-2 positivity on reverse transcription-polymerase chain reaction was confirmed. Further revisions for intrahepatic hematoma with hemorrhagic shock and abdominal compartment syndrome were performed. Subsequently, the patient developed hemoptysis, which was treated using bronchoscopic therapy and non-invasive ventilation. Liver tissue biopsy revealed hemorrhagic foci and necrosis with an irregular centrilobular distribution. Antiphospholipid syndrome and autoimmune hepatitis were also ruled out. Fetal death was caused by acute intrauterine asphyxia.

CONCLUSION

This case reveals that pregnant women with SARS-CoV-2 infection may be predisposed to liver parenchyma disease with liver rupture.

Rupture of suppurated liver hematoma into the anterior abdominal wall in a patient with Rendu-Osler-Weber syndrome

We report a case of ruptured liver hematoma as a result of suppurated arteriovenous malformation (AVM) in a patient with Rendu-Osler-Weber (ROW) syndrome. The patient presented with unexplained fever and upper right abdominal pain associated with microcytic anemia. A computed tomography scan revealed increasing subcapsular liver hematoma and features of liver abscess. Intraoperatively, a left liver hematoma mixed with pus was found that was attached to the anterior abdominal wall. Surgery included left lateral bisegmentectomy, while pathohistological analysis showed AVM and genetic tests confirmed ROW. This is the first such life-threatening surgical case of ROW complication reported in the scientific literature.

Post-traumatic rupture of the right ovary and liver after blunt abdominal trauma: A case report

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Traumatic rupture of the ovary due to blunt abdominal trauma is very rare and usually connected to ovarian cyst or teratoma.

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FAST and CT-angiography missed the ovary rupture, which was revealed by the exploratory research laparotomy.

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In a hemodynamic instable patient hemostasis is performed by ovarian artery ligation through laparotomy.

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Injury of the ovary should always be included in the differential diagnosis of blunt abdomen trauma in female patients.

Introduction

Traumatic rupture of the ovary, due to blunt abdominal trauma, is rarely described in literature and is usually related to ovarian cyst or teratoma.

Presentation of case

A 21-year-old Greek, female patient was transported to the Emergency Department complaining of abdominal pain as a result of a catapulting fall from a bicycle. It was determined that both right ovary and liver rupture had occurred. The patient was treated with rinsing of the peritoneal cavity, subhepatic packing and right ovary hemostasis.

Discussion

Traumatic rupture of the ovary, due to blunt abdominal trauma, is very rare and is usually connected to former ovarian cyst or teratoma. This is the first such ever documented case in Greece.

Conclusion

Although rare, injury of the ovary following blunt abdominal trauma, should always be included in the differential diagnosis of acute abdomen in female patients.

[Cardiac post-resuscitation care. An indication for trauma whole-body CT?]

We report the case of a 51-year-old male patient who sustained a liver rupture following mechanical cardiopulmonary resuscitation (CPR) with the LUCAS® system. The patient was under anticoagulation and developed an abdominal compartment syndrome. Although the use of mechanical CPR devices, such as the LUCAS® system and the load distributing band (Autopulse®), is becoming more common, there are specific complications described in the literature, which are associated with mechanical CPR. It is important to differentiate between general complications associated with CPR and those which can be attributed to the application of mechanical CPR devices. Using the example of the presented case, this article outlines and discusses these points based on the currently available literature. It should also be noted that mechanical CPR can act in a similar way to chest trauma and can necessitate an investigation with contrast enhanced computed tomography.

Management of Spontaneous Hepatic Rupture on Top of HELLP Syndrome: Case Report and Review of the Literature

Introduction

We report the case of a patient with antepartum HELLP syndrome and simultaneous rupture of the right liver lobe. An emergency caesarean section was performed and the liver rupture was managed surgically via perihepatic packing. The mother and her child recovered well and were discharged 19 days after admission.

Case Report

We describe a case report and review the literature. Based on our own experience and the most common clinical presentations of such patients, we were able to establish an algorithm for managing such cases.

Conclusion

An association between liver rupture and HELLP syndrome is rare but was previously described in several case reports. In pregnant women with HELLP syndrome and acute onset abdominal pain, a potential spontaneous hepatic rupture should be taken into consideration.

Spontaneous rupture of the liver in a patient admitted for subarachnoid hemorrhage

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Spontaneous rupture of the liver is a rare event often associated with the presence of malignant liver disease or occurring in the context of a HELLP syndrome.

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The treatment of hemorrhage due to spontaneous rupture of the liver includes, in addition to serial monitoring of hemoglobin values, in cases of unstable patients, embolization, hepatic resection and packing.

INTRODUCTION

Spontaneous rupture of the liver is a rare event often associated with the presence of malignant liver disease or occurring in the context of a HELLP syndrome.

We present a case of spontaneous rupture of the liver in a patient admitted to our Intensive Care Department with hemoperitoneum in the aftermath of recent surgical clipping of a cerebral aneurysm.

PRESENTATION OF CASE

We report a 50-year-old woman who was transferred from the Bolzano Hospital Department of Neurosurgery to the Intensive Care Unit with anemia and the occurrence of major abdominal pain.

DISCUSSION

Spontaneous hepatic rupture remains a rare event, associated more often than not with pregnancy or traumatic events. The treatment of hemorrhage due to spontaneous rupture of the liver includes, in addition to serial monitoring of hemoglobin values, in cases of unstable patients, embolization, hepatic resection and packing.

CONCLUSION

The case described here shows that spontaneous rupture of the liver may be due to indefinable causes and that its treatment remains complex and multidisciplinary.

Ovarian stimulation and liver dysfunction: Is a clinical relationship possible? A case of hepatic failure after repeated cycles of ovarian stimulation

Liver damage induced by ovarian stimulation has been demonstrated in some cases reported in the literature. However, there has never been a fruitful debate on this topic. The present manuscript tried to fill this gap. We reported a case of a 35-year-old nulliparous woman admitted to our obstetric emergency room for severe pre-eclampsia. She had been subjected to four cycles of controlled ovarian stimulation for intrauterine insemination. At 32 weeks of gestation, she developed severe pre-eclampsia, which led to HELLP syndrome complicated by fatal liver failure. The etiological link between ovarian stimulation and HELLP syndrome is intriguing. Further investigations are needed to understand whether repeated ovarian stimulation may represent a risk factor in pre-eclamptic patients.

Spontaneous rupture of intrahepatic bile duct following portal vein embolization in a patient with perihilar cholangiocarcinoma: a case of successful curative resection

We herein present a case of spontaneous rupture of intrahepatic bile duct in a patient with perihilar cholangiocarcinoma, which were successfully treated by curative resection. A 60-year-old male patient with perihilar cholangiocarcinoma was decompressed with single percutaneous transhepatic biliary drainage. Two days after right portal vein embolization, the patient suffered from paralytic ileus with marked abdominal distension. Imaging study revealed that marked fluid collection around the liver and whole abdomen, suggesting intrahepatic bile duct rupture. With abdominal drainage and biliary decompression for 2 weeks, the biliary rupture was controlled. To enhance the safety of right hepatectomy, additional right hepatic vein embolization was performed. The patient underwent routine surgical procedures for right hepatectomy, caudate lobectomy and bile duct resection, and recovered uneventfully and discharged 18 days after surgery. This is the first report of a case of spontaneous rupture of intrahepatic bile duct in a patient with perihilar cholangiocarcinoma.

Surgical treatment of patients with traumatic liver rupture: An analysis of 23 cases

AIM: To summarize our experience with surgical treatment of 23 patients with traumatic liver rupture.

METHODS: The clinical data for 23 patients with traumatic liver rupture who were surgically treated from 2006 to 2011 at our hospital were retrospectively analyzed.

RESULTS: Of 23 patients with traumatic liver rupture, 20 were cured and 3 died. One patient died of multiple organ injury. Rupture of the liver, spleen and kidney, and pelvic fracture occurred in this patient. One patient died of severe chest trauma with acute respiratory distress syndrome (ARDS), and the other patient died of multiple organ failure (MOF) after surgery for liver rupture. The death rate was higher in patients with serious liver rupture or with combined MOF. Early and accurate diagnosis and proper and timely surgical treatment are key to saving the lives of patients and improving the cure rate and death rate.

CONCLUSION: Proper and timely surgical treatment can improve survival and reduce complications in patients with traumatic liver rupture who require surgical treatment.