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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 .
the cases reported in the literature refer to hepatic rupture in pregnancy or cases in the context of the rupture of a hepatocellular adenoma , in idiopathic peliosis hepatis and other more rare conditions such as coagulation disturbances and connective tissue disease like amyloidosis .
the clinical case described here is one of a female patient admitted to our intensive care department for spontaneous rupture of the liver in the aftermath of recent surgical clipping of a cerebral aneurysm .
a 50-year - old woman was transferred from the bolzano hospital department of neurosurgery to the intensive care unit as a result of anemia ( hemoglobin down to 8.2  g / dl ) and the occurrence of major abdominal pain in the right hyperchondrium . on examination ,
the patient was normotensive ( blood pressure 125/70  mmhg , pulse rate 90/min ) and had a firm , tender abdomen .
an ultrasound examination of the abdomen was performed , showing a fluid collection in the perihepatic region and in the pelvic area , partly with an echogenic appearance .
the patient had been admitted a week earlier to the neurosurgery department following a subarachnoid hemorrhage due to a bleeding aneurysm of the right pericallosal artery , treated with a right frontal craniotomy and clipping .
the patient and her husband denied the possibility of a trauma related to the cerebral hemorrhage .
an abdominal ct scan was performed with contrast medium showing a voluminous fluid collection in a subcapsular site along the ventral margin of the liver . in the context of this collection , moreover
, the presence of a circumscribed leakage of arterial contrast medium was observed at the level of the 4th segment .
a diffuse fluid collection was also present in all the peritoneal recesses ( figs . 1 and 2 ) .
the patient was then given a blood transfusion with 2 units of packed red blood cells with an increase in hemoglobin from 8.2 to 8.7  g / dl .
the patient was subjected to hepatic angiography which revealed no signs of arterial leakage of contrast medium , but showed multiple petechial images in the peripheral portions of the hepatic parenchyma .
we then proceeded with reversible gelatin sponge embolization of the branches for the central hepatic segments and the left lobe .
the patient was stable from the hemodynamic point of view ( blood pressure 140/70  mmhg , pulse rate 95/min ) , with increased lactates ( 64  mg / dl ) , and tended to be oliguric .
as regard laboratory tests , there was a marked increase in liver function indices ( ast 4092 
u / l ) , with normal value of bilirubin and coagulation profile . in the hours following embolization ,
the patient presented a new reduction in hemoglobin to 6.9  g / dl and an increase in lactates above 80  mg / dl .
resection of the 7th and 8th hepatic segments and packing of the liver were performed . during the operation
the patient was given massive blood transfusions with 11 units of packed red blood cells , 1800  ml of fresh frozen plasma , 1 platelet concentrate and 4  g of fibrinogen .
the patient 's clinical condition was stable during the 72  h after the operation with hemoglobin values of 9  g / dl , and without any need for blood transfusions .
however , the patient was subjected to renal replacement therapy in cvvhdf due to the presence of oligoanuria and a tendency to develop metabolic acidosis . on postoperative day 3
, the patient was taken once again to the operating theater where she underwent a depacking operation .
twelve days after admission to the intensive care department the patient was transferred to the surgery department , awake and contactable , and stable from the hemodynamic and respiratory points of view .
the patient 's hemoglobin values remained stable at 9.5  g / dl , her liver parameters reverted to normal and she resumed urinating spontaneously .
the pathology report relating to the liver resection slice on the day of the first operation described a capsular  parenchymal laceration with subcapsular blood extravasations , together with diffuse ectasia and vascular congestion , and multiple , partly confluent areas of hemorrhagic necrosis .
the pathologist suggest to exclude the posttraumatic origin of the lesion and to evaluate the possibility of a recent stroke or an acute heart failure .
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 . in the case
described , the recent history of bleeding from a cerebral aneurysm led us to believe that initially an abdominal trauma had gone unrecognized .
the patient and her husband consistently denied any such trauma , inasmuch as the patient had presented acute cerebral symptoms , headache and vomiting while seated at table .
furthermore the cerebral bleeding was not correlated with an evidence of vasculitis or others connective diseases in the pathology findings .
the therapeutic approach adopted was characterized by two phases : the first consisted in angiography , revealing no active site of bleeding , while the second , the liver resection and packing surgery , achieved definitive hemostasis .
though the angiographic study did not show a significant blush of contrast medium , there was multiple petechial images in the peripheral portions of the hepatic parenchyma .
the embolization was performed with reversible gelatin sponge following the ct scan that showed a spotty extravasation of the branches for the central hepatic segments and the left lobe .
transarterial embolization was chosen as the first option , in that the procedure is less invasive compared to exploratory laparotomy and surgical treatment and less risky for the patient , but in our case it failed to resolve the problem of controlling the bleeding .
surgical treatment was postponed because the patient presented stable vital parameters , considering from the outset the possibility of the rupture of a hepatic angioma , the bleeding of which is often self - limiting .
the intraoperative macroscopic appearances and the pathology findings relating to the liver resection slice excluded the possibility of this cause , in that a capsular  parenchymal laceration was described with subcapsular hemorrhagic extravasations , vascular congestion and multiple areas of hemorrhagic necrosis without any evidence of malignancy .
a clinical  pathological correlation between cerebral and liver bleeding should be confirmed from the presence of an inflammatory process , microaneurysms , vasculitis or hepatic failure .
the laboratory tests , the ct scans and the pathology findings did not evidence these diseases .
spontaneous hepatic rupture not associated with pregnancy or with the presence of a liver tumor remains a rare event , requiring combined treatment consisting in close clinical monitoring , transarterial angiography and possibly surgical intervention .
diagnosis of liver rupture is not easy and can be made on the basis of clinical examination , laboratory tests and abdominal imaging .
however , the etiology of liver rupture remains difficult almost in some cases in then the right succession of events is not clear . a thorough history taking of
the patient must rule out abdominal trauma and the presence of pathological conditions including rare diseases such as idiopathic peliosis hepatis or amyloidosis . in our case , we were unable to uncover the real cause of liver bleeding .
subclinical trauma remains a remote possibility since the husband denied a history of fall or blunt injury . at the time of onset of the first symptoms the patient was seated on the table .
the vomiting could have caused the rupture of the liver , in accordance with the location of the laceration , the ventral surface that is in strictly contact with the costal margin .
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 .
marianna zatelli contributed in writing and data collection , and alessio comai contributed in figure collection .
highlightsspontaneous 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.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 .