Intrahepatic rupture

Lupetin, A.R., Dash, N. Intrahepatic rupture of hydatid cyst MR findings. Amer. J. Radiol. 1988 151 491-492... 

Intrahepatic rupture can result in hemobilia with or without biliary obstruction. These patients can present with right upper quadrant pain, jaundice, fever, melena, or hematemesis. Extrahepatic rupture usually presents acutely and can lead to exsanguination due to massive intraperitoneal hemorrhage. They can erode into adjacent structures such as the stomach, common bile duct, duodenum, or portal vein. Due to the high mortality from rupture, elective treatment of small asymptomatic aneurysms has been advocated. 

Portal hypertension most commonly occurs as a consequence of chronic liver disease. Portal hypertension Is caused by Increased blood flow within the portal venous system and increased resistance to portal flow within the liver. Splanchnic blood flow is increased in patients with cirrhosis due to low arteriolar resistance that is mediated by increased circulating vasodilators and decreased vascular sensitivity to vasoconstrictors. Intrahepatic vascular resistance is increased in cirrhosis due to fixed fibrosis within the spaces of Disse and hepatic veins as well as reversible vasoconstriction of hepatic sinusoids and venules. Among the consequences of portal hypertension are ascites, hepatic encephalopathy, and the development of portosystemic collaterals—especially gastric or esophageal varices. Varices can rupture, leading to massive upper gastrointestinal bleeding. 

Percutaneous splenoportography has lost its importance. Should a direct procedure be indicated, laparoscopic splenoportography is a possible alternative. Recently, a new technique has been described. (134) The percutaneous splenic puncture is performed using a thin needle under screen control, with the needle directed at the splenic hilus. The pressure of the splenic pulp can be measured directly in order to estimate the portal vein pressure. Contrast medium is injected manually or by a special device. From this depot in the red pulp, the splenic vein, the portal vein and the intrahepatic branches of the portal vein are contrasted within a few seconds, (s. fig. 8.12) Complications resulting from percutaneous splenoportography include afterbleeding from the spleen, bilateral rupture of the spleen, arterial aneurysms and a.v. shunts — these complications are serious in nature, but rare. Contraindications for the procedure should be carefully observed, (s. tab. 8.6)... 

Barange, K., Peron, XM., Imani, K., Otal, R, Payen, XL., Rousseau, H., Pascal, J.R, Joffre, F., Vinel, XR Transjugular intrahepatic portosystemic shunt in the treatment of refractory bleeding from ruptured gastric varices. Hepatology 1999 30 1139-1143... 

After perforation (60-80% of patients), an aneurysm becomes manifest in the form of abdominal pain, which can be very severe. (129) When an intrahepatic haema-toma reaches the bile ducts, haemobilia may result (about 40% of cases) (133), just as compression of the excretory bile ducts may lead to the development of jaundice (in some 50% of cases). (134,138) Heavy bleeding into the free abdominal cavity constitutes an acute abdomen with signs of circulatory shock. Bleeding into the intestinal tract or into the portal vein is less frequent. Lethality due to rupture is 30-50% the prognosis for massive bleeding with haemoperitoneum is even poorer. 

Okur, N., Inal, M., AkgnI, E., Demircan, O. Spontaneous rupture and thrombosis of an intrahepatic portal vein aneurysm. Abdom. Imag. 2003 28 675 -677... 

Hepatic cysts can also be part of polycystic liver disease, an autosomal dominant disorder often found in association with renal polycystic disease (van Sonnenberg et al. 1994). It is due to a ductal plate malformation of the small intrahepatic bile ducts, which loses communication with the biliary tree. It is characterized by the presence of multiple, sometimes innumerable cysts ranging in size from less than 1 cm to more than 12 cm spontaneous intracystic hemorrhage, infection, and rupture may occur. Usually, patients with autosomal dominant polycystic liver disease are asymptomatic and liver dysfunction occurs rarely... 

Bilomas result from rupture of the biliary system, which can be spontaneous, traumatic, or iatrogenic following surgery or interventional procedures (Mortele and Ros 2001 Murphy et al. 1989). Bilomas can be intrahepatic or perihepatic. Extravasation of bile into the liver parenchyma generates an intense inflammatory reaction, thereby inducing formation of a well-defined pseudocapsule. Clinical manifestations depend on the location and size of the biloma (Mortel and Ros 2001 Murphy et al. 1989). 

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