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Liver Hematoma
Subcapsular liver hematoma is another serious hemorrhagic
complication that has been rarely observed in uremic patients.
From: Handbook of Dialysis Therapy (Fifth Edition), 2017

Related terms:

Hemolysis, Pre-Eclampsia, HELLP Syndrome, Elevated Transaminases, Lesion,

Liver Injury

Liver, Biliary, and Pancreatic Injury

D. DEMETRIADES, ... C.V.R. BROWN, in Surgery of the Liver, Biliary Tract and
Pancreas (Fourth Edition), 2007

Liver Hematomas
Many liver hematomas can be managed safely nonoperatively, provided that the
patient is hemodynamically stable and has no peritonitis. The discovery of a stable
subcapsular or intrahepatic hematoma during an exploratory laparotomy poses a
major dilemma for the surgeon. Exploring these hematomas may precipitate
significant bleeding, whereas failure to do so may result in delayed rupture and
bleeding. Management is controversial; we suggest that deep, stable
intraparenchymal hematomas and small or moderate size subcapsular hematomas
be left undisturbed. To rule out bleeding and false aneurysms, postoperative
evaluation with contrast CT scan is essential, especially in large intrahepatic
hematomas. Large subcapsular hematomas should be explored, and any
underlying liver lacerations should be sutured and hemostasis achieved, if
necessary, with perihepatic packing.

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Liver Lesion With Capsule or Halo on MR

In Expertddx: Abdomen and Pelvis (Second Edition), 2017

Hepatic Hematoma
This young woman had recent liver transplantation and has an encapsulated
hepatic lesion

that is bright on T2WI, typical of a subacute hematoma. The midline signal void

is an artifact due to metallic clips and coils.

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Hepatic Hematoma
In this young woman with a perihepatic hematoma following liver transplantation,
an axial T1WI FSE MR shows a lesion with a bright rim or capsule

Hepatic Adenoma
This 25-year-old woman has a mass that was substantially hypodense to the liver
(not shown, likely on the basis of lipid content). Arterial-phase CECT shows
heterogeneous hypervascularity of the mass

Hepatic Adenoma
In this 25-year-old woman, the hepatic mass is encapsulated

. The hypodensity of the mass is indicative of lipid content, another typical feature
of hepatic adenoma.

Hepatic Adenoma
This young woman has a hepatic mass

that is encapsulated and slightly hyperintense to background liver on this in-phase

GRE MR.

Hepatic Adenoma
This young woman has a hepatic mass that shows selective signal loss on this
opposed-phase GRE T1W MR, indicative of lipid content and characteristic of
hepatic adenoma.

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Focal liver lesions/echo enhancing agents and the liver

Gavin Low, Edward Leen, in Clinical Ultrasound (Third Edition), 2011

Liver haematoma
Liver haematoma is most commonly caused by blunt abdominal trauma, with the
liver being the second frequent abdominal organ injured during blunt trauma
(after the spleen). The liver is susceptible to trauma due to its large size (the largest
intra-abdominal organ), its relatively fixed position in the abdomen and its
proximity to bony structures such as ribs and spine. Other predisposing causes for
liver haematoma include surgery, liver biopsy, coagulopathy, intra-tumoral
haemorrhage and pregnancy. Hepatic haematomas are also frequently found in
newborns at perinatal autopsy, but are usually small, subcapsular in location and
clinically silent.98 It is postulated that the delicate hepatic capsule and its
connections to the collagen along the sinusoids provide the pathogenesis of these
haematomas in neonates.98
Haematomas may have variable shapes and echogenicity. Subcapsular
haematomas typically have a lentiform shape which conforms to the outer contour
of the liver capsule. Intraparenchymal haematomas are typically spherical with
irregular walls but may also follow given anatomical structures resulting in a more
starlike configuration.99 The ultrasound appearance of haematoma depends on the

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severity of the bleed and the timing of the scan relative to the onset of bleeding.100
Acute and subacute haematomas appear homogeneous and hyperechoic (due to
multiple acoustic interfaces as a result of the fibrin and erythrocytes in the
haematoma), whereas in chronic cases, the haematoma appears more cystic with
internal echoes due to clot liquefaction.100 Fluid–fluid levels can be seen in
haematomas due to the haematocrit effect. Internal septations, which float freely
during real-time scanning and which do not show vascularity on colour Doppler
US interrogation, are a recognised finding. Serial US will show a change in size and
appearance of the haematoma with time. Eventually, over a period of months, the
haematoma will resolve due to regeneration of liver tissue, but a residual scar or
cystic space may persist. On CEUS, haematoma is hypoechoic on all vascular
phases. Haematomas secondary to intra-tumoral haemorrhage in a pre-existing
hepatic neoplasm will show avascularity of the haematoma juxtaposed with the
vascular pattern of the underlying tumour. CEUS is a useful supplement to
conventional US in the assessment of trauma patients, with studies showing
superior detection of solid organ injuries with CEUS compared to conventional
US.101,102 Liver lacerations typically appear as well-defined hypoechoic linear or
branched areas while contusions appears as ill-defined hypoechoic areas without
clearly defined margins – these are best appreciated on the portal venous phase103
(Fig. 10.11). Active haemorrhage is identified as an extravasation of microbubbles
into the haematoma and suggests a more clinically significant injury. Performance
of CEUS may almost approach that of contrast CT in the assessment of trauma
patients, and CEUS may have a role in the triage of trauma patients who cannot
undergo CT due to haemodynamic instability but who could have a bedside
ultrasound examination in the emergency unit.101 In addition, CEUS could be used
in the follow-up of hospitalised patients with known solid organ injuries who are
managed conservatively and who cannot be easily moved to the CT suite.101

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HELLP Syndrome
In Diagnostic Imaging: Gastrointestinal (Third Edition), 2015

IMAGING
General Features
• Best diagnostic clue
○ Intrahepatic or subcapsular fluid collection (hematoma) on US, CT, or MR
CT Findings
• Liver hematomas
○ Well-defined, hyper- or hypodense, depending on physical state of blood
○ Nonenhancing
○ Acute: Hyperattenuating clot (24-72 hours)
○ Chronic: Decreased attenuation after 72 hours (lysed clot)
• Liver infarction
○ Small or large areas of low attenuation, usually peripheral and wedge
shaped
○ May be indistinguishable from steatosis of pregnancy
• Occasionally active contrast extravasation or ascites
○ Active bleeding is serious; may require embolization or surgery
MR Findings

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• Hemorrhage and necrosis (often coexist)

○ T1WI and T2WI
– T1WI: Low signal intensity
– T2WI: High signal intensity
– Varied signal intensity based on
□ Degree and age of hemorrhage, infarct, or steatosis
□ Greater degree of edema and cellular necrosis in infarction
Ultrasonographic Findings
• Grayscale ultrasound
○ Irregular or wedge-shaped liver hemorrhage or infarct with increased
echogenicity; usually peripheral
○ Periportal halo sign: Hyperechoic thickening of periportal area
○ Subcapsular hematoma: Complex echogenic fluid collection
○ Enlarged liver (predominantly right lobe)
○ Occasionally ascites, may be complex (hemorrhagic)
• US features may be seen before increase in biological markers (41% of cases)
Imaging Recommendations
• Best imaging tool
○ Ultrasonography is least invasive, often sufficient
– Can depict intra- and perihepatic hemorrhage
– Limited view of abdomen and pelvis (due to gravid uterus)
• Protocol advice
○ MR and CT offer larger field of view
○ Indicated when there is concern for hepatic rupture or hemorrhage (e.g.,
hypotension, right shoulder pain)

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Hepatic Hemorrhage
In Diagnostic Pathology: Hospital Autopsy, 2016

(Left) This hepatic hematoma

occurred after percutaneous biliary drain placement, which resulted in portal vein
injury and arterial-portal venous fistula formation (confirmed on premortem
hepatic angiogram).

(Right) Section through the hematoma

shows adjacent hepatic parenchyma with patchy coagulative necrosis

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(Left) Hemoperitoneum

occurred after percutaneous liver biopsy in a patient on anticoagulant therapy.

Note the liver

and gallbladder

(Right) The inflammatory (a.k.a. telangiectatic) type of hepatocellular adenoma is

characterized by portal tract-like structures containing inflammatory infiltrates

and marked sinusoidal dilatation

(Left) A microscopic focus of the parenchymal pattern of peliosis hepatis in a patient

with a history of anabolic steroid use shows sinusoidal dilatation

and an irregular blood-filled space

with associated hepatocellular necrosis

(Right) A cavernous hemangioma is composed of blood-filled spaces

lined by bland, flattened endothelial cells

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Liver and spleen

Bastiaan de Boer, in Orell and Sterrett's Fine Needle Aspiration Cytology (Fifth
Edition), 2012

Complications
No deaths and only one significant complication, an intrahepatic hematoma,
occurred in an early report of 2611 cases.45 A later summary of 7500 FNAs from 11
series recorded no deaths.46 In an extensive literature review and questionnaire
study,47 Smith collated fatalities following abdominal percutaneous FNA. Of 21
deaths involving liver FNA, he noted that 17 were due to hemorrhage. A needle
larger than 0.8 mm (21 gauge) was used in seven. Three of the other 10 followed
FNA of vascular tumors (hemangioma 1, angiosarcoma 2). Fatalities due to other
causes were rare (sepsis 2, carcinoid crisis 1, uncertain 1). More recently, two
deaths due to hemorrhage from among 1750 US guided FNA has been reported.48
Allegations of needle track spread of tumor have always dogged FNA, and the liver
is no exception in this regard. Of recent concern has been a number of literature
reports of subcutaneous seeding of needle tracks from otherwise operable
HCCs.47,49–51 Whereas in some of these reports the procedures comply in every
respect with the usual safety precautions advised (0.8-mm/21-gauge needles or
smaller, few needle passes, traversal of normal liver parenchyma between

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abdominal wall and tumor),52 other reports often included in discussion of this
issue have used 18-gauge needles,53 have traversed one lobe to reach a lesion in
the other lobe and have not defined needle size,54 or are series in which cutting55
or Trucut56 needles have been used. Cytopathologists and radiologists performing
hepatic FNA should discuss and be very clear about the caliber of needles used.
In those cases in which potentially resectable or transplantable HCC is being
investigated, local opinion might preclude preoperative sampling.9 This is despite
studies that show FNA has no significant adverse effect on operability, extrahepatic
metastases or long-term survival.6,8,57 Experience with cases of needle track spread
has shown that local treatment by resection has been successful for isolated
subcutaneous tumor deposits.47,49,53–56 In the vast majority of hepatic aspiration
procedures, physicians and patients can be assured of very low complication rates
(hemorrhage 0.006–0.031%, needle track spread 0.007%).47

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Platelets, Coagulation, and the Liver

Louise Kenny, ... F. Gary Cunningham, in Chesley's Hypertensive Disorders in
Pregnancy (Third Edition), 2009

Hepatic Hematoma and Subcapsular Hematoma

Bleeding from periportal lesions or hemorrhage into infarcts may cause an
intrahepatic hematoma with or without rupture. Alternatively, hemorrhage may
extend beneath the hepatic capsule – Glisson capsule – and form a subcapsular
hematoma. These latter lesions without rupture are probably more common than
previously suspected.140,141 They are especially more likely with HELLP syndrome
and contribute to its increased mortality.
Management of both forms of hepatic hematomas depends on the clinical
circumstances. In most cases, observation and conservative treatment is usually
elected, unless hemorrhage is ongoing. That said, in some cases, prompt surgical
intervention may be life saving. Shrivastava et al.142 obtained hemostasis in one
woman in whom an argon beam coagulator was used. Merchant et al.143 reported
successful use of recombinant VIIa to help control hepatic hemorrhage in three
women with a subcapsular hematoma – one of these women did not survive.
Rinehart et al.144 reviewed 121 cases of spontaneous hepatic rupture associated
with preeclampsia and reported the maternal mortality rate to be 30%. Hunter et
al.145 and Wicke et al.146 each described similar women in whom liver transplant
was considered life saving.

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Biochemistry of Hellp Syndrome

Chiara Benedetto, ... Loredana Salton, in Advances in Clinical Chemistry, 2011

2.3 Maternal and Perinatal Outcome

The HELLP syndrome is associated with both maternal and neonatal
complications. Spontaneous rupture of a subcapsular liver haematoma in
pregnancy is a rare but life-threatening complication that occurs in less than 1% of
the cases with the HELLP syndrome. Rupture most often occurs in the right liver
lobe [4, 22–24]. More common and serious maternal complications are abruptio
placentae, disseminated intravascular coagulation, and subsequent severe
postpartum bleeding, retinopathy, cerebral bleeding, and stroke [25–32]. In a large

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retrospective cohort study comprising 442 pregnancies complicated by the HELLP

syndrome, the maternal mortality was 1.1% [2], which is in accordance with other
reports [4,33,34]. Isler et al. found cerebral hemorrhage or stroke to be the primary
cause of death in 26% and the most contributing factor in another 45% of the
deaths [35]. Maternal mortality rate in hepatic rupture ranges from 18% to 86% [8].
Perinatal mortality and morbidity are considerably high in the HELLP syndrome
and are primarily dependent on the gestational age at onset [36,37]. The perinatal
mortality rate related to the HELLP syndrome is between 7.4% and 34% [4,38,39].
Neonates delivered before completion of 32 weeks' gestation have the highest risk
of perinatal death [36,37].

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Laparoscopic Nissen Fundoplication

Stephen R.T. Evans MD, Elizabeth A. David MD, in Surgical Pitfalls, 2009

Liver Hematoma
Because of retraction of the left lateral segment of the liver to expose the GE
junction and hepatogastric ligament, liver hematomas and retraction injuries are
not uncommon but rarely lead to serious complications other than pain and
discomfort. Pasenau and colleagues31 reviewed retraction injuries associated with
LNF and reasserted the requirement for gentle retraction and use of atraumatic
and blunt instruments to reflect the left lateral segment to allow full exposure.
Specifically, they asserted that the type of retractor, the size of the patient's left lobe
of the liver, and the force applied on the retractor all contribute to safe retraction.
They suggested monitoring the color of the retracted liver during difficult cases to
indicate when a pause in the procedure may be appropriate to prevent ischemia or
venous engorgement injuries.31

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Surgical Management of Cystic Disease of the Liver

D.M. NAGORNEY, J.M. SARMIENTO, in Surgery of the Liver, Biliary Tract and
Pancreas (Fourth Edition), 2007

MISCELLANEOUS CYSTS
Miscellaneous cysts of the liver include traumatic cysts and neoplastic cysts.
Traumatic cysts are rare and usually form after incomplete resolution of
subcapsular or intrahepatic hematomas or bilomas. They are usually single and
have a thick pseudocyst wall and contain thick, bile-stained contents and
hematoma. Because traumatic cysts are formed by parenchymal and ductal
disruption, they have no epithelial lining. Most traumatic cysts resolve
spontaneously. Occasionally, however, an intraparenchymal cyst may persist. If
traumatic cysts continue to enlarge, disruption of a major segmental bile duct,
which lacks continuity with the extrahepatic duct, must be suspected. If the cyst is
symptomatic, complete resection or partial resection with intraperitoneal
marsupialization and closure of the ductal defect is effective treatment.
Cystadenomas or cystadenocarcinomas constitute true neoplastic hepatic cysts. As
with cystadenomas elsewhere intra-abdominally, they may be serous or mucinous,
although the latter is more common. Cystadenomas are more common in women,
and clinical presentation is similar to that of large simple cysts. Preoperative
imaging characteristics have been addressed previously. Prominent intraductal

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septa and focal wall thickening with or without mural nodularity are the hallmarks
of cystadenomas on imaging studies. Although the presence of septations or
nodular projections within the cyst on imaging classically differentiates
cystadenomas from simple cysts, cystadenomas frequently are unilocular. Cyst
aspirates may contain elevated levels of CA 19-9 or carcinoembryonic antigen, but,
to date, the diagnostic value of these markers is indeterminate, and testing is not
routine. If cystadenoma is suspected clinically, complete excision is indicated.
The results for treatment of cystadenomas after excision have been excellent.
Partial excision has been associated with a high (>60%) recurrence rate (Davies et
al, 1999). Any cyst in which a biopsy has been performed and cystadenoma
confirmed requires complete excision. There are two histopathologic subtypes of
cystadenomas: (1) simple cystadenoma and (2) cystadenoma with mesenchymal
stroma. The latter type of cystadenoma occurs exclusively in women. Although
histologically distinct, both subtypes seem to have similar clinical presentation and
outcomes (Akwari et al, 1990; Wheeler & Edmonson, 1985).
Mucinous cystadenomas have a malignant potential and require complete excision.
Adenocarcinomas may arise from the epithelial lining of a cystadenoma.
Cystadenocarcinomas are exceedingly rare, and few have been reported (Ishak et al,
1977). The frequency of liver cysts harboring malignancy is so rare that the
possibility of malignancy does not constitute an indication for excision of all cysts.
Even symptomatic simple cysts are unusual. If cyst excision is undertaken, any
irregularity of the cyst wall requires biopsy to exclude cystadenocarcinoma. If
carcinoma is diagnosed, formal hepatic resection is recommended. Hepatic
resection may be complicated because of the gross distortion of the intrahepatic
ductal anatomy splayed over the cyst wall. Despite this intrahepatic ductal
distortion, wide excision with adequate tumor-free margins is required.
Consequently, extended lobar resections usually are required. Reported outcomes
of hepatic resection for hepatic cystadenocarcinoma are few. Long-term survival
has been obtained only after complete excision (Ishak et al, 1977; Wheeler &
Edmonson, 1985). Complications associated with excision of cystadenocarcinomas
have been similar to that of hepatic resections for intrahepatic malignancies.
Ciliated hepatic foregut cyst is a rare condition with fewer than 60 reported cases
worldwide. This cyst likely is related to a developmental anomaly of the anterior
foregut, leading to a detached outpouching of the hepatic diverticulum or enteric
foregut. The cysts are typically small, solitary, and uniloculated. They contain
ciliated pseudostratified columnar epithelium, scattered mucosal cells, loose
subepithelial connective tissue, and a fibrous external capsule. They are benign
with a low malignant potential (two reported cases). Although typically
asymptomatic, resection usually is undertaken because of the inability to
distinguish them from neoplastic cysts (Momin et al, 2004).
Hepatic cysts secondary to radiofrequency ablation are seen increasingly.
Coagulative necrosis of the tumor and the adjacent hepatic parenchyma causes a
radiofrequency ablation cyst (pseudocyst). Necrosis of adjacent bile duct or vessel
may affect cyst composition. Resolution is typical, but variable in duration.
Infection of radiofrequency ablation cysts is common in the presence of prior
biliary drainage procedures or patent sphincterotomy. An infected radiofrequency
ablation cyst should be managed as a hepatic abscess.

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