- Email: [email protected]
Hematemesis due to trauma of the liver
HEMATEMESIS DUE TO TRAUMA
OF THE LIVER*
LOUIS HERMANSON,M.D. AND HENRY L. CABITT, M.D. BOSTON
H
EMATEMESIS
occurs with such frequency that its usua1 causes are common knowIedge. Ordinarily onIy Iesions invoIving the upper gastrointestina1 tract are considered in the differentia1 diagnosis of this symptom. To this practice may be ascribed occasiona errors in diagnosis. The purpose of this paper is to
report an unusua1 cause for hematemesis and to call attention to simiIar infrequent causes. CASE REPORT D. S. No. 17598. A sixteen-year-oId schooIboy was admitted on April 8, 1933 compIaining of pain in the right shouIder of three hours’ duration. He stated that whiIe running he feII against a curbstone, faIIing on the right upper abdomen and on the Iower right chest anteriorIy. This was folIowed immediateIy by pain in the right upper quadrant and in the tip of the right shouIder. The pain was constant, and associated with progressive weakness. Physical examination reveaIed an acuteIy III boy with marked paIIor of the skin and mucous membranes. The extremities were coId and cIammy. There was a red weIt extending across the Iower anterior portion of the right chest and the right upper quadrant. The abdomen was sIightIy distended and there was tenderness and spasm in the epigastrium and in the right upper quadrant. There was marked tenderness in the right costovertebra1 angIe. The temperature was IO~‘F., puIse 104, respirations 28, B.P. 120/70. The examination was otherwise negative. Clinical Pathology: The white bIood count was 21,000; Hb. go (T.); red bIood count 4,100,000. The urine contained a sIight trace of aIbumin and 30 red bIood ceIIs per high power fieId. Diagnoses of ruptured Iiver, ruptured right kidney, ruptured viscus, and intraperitonea1
hemorrhage were made. Because of the possibiIity of ruptured viscus, Iaparotomy was performed shortIy after admission. Under general anesthesia the abdomen was opened through a high right paramedian incision. ExpIoration reveaIed a Iarge amount of free bIood in the peritonea1 cavity. There was an obIique tear through the upper surface of the right Iobe of the Iiver corresponding in direction to that of the overIying rib. The tear was very superficia1 IateraIIy, but deep mediaIIy. There was edema of the gastrohepatic omentum. A sIight rupture of the Iower poIe of the right kidney with a moderate intracapsuIar hemorrhage was noted. The tear in the Iiver was packed with gauze and the abdomen was cIosed. ConvaIescence was not remarkabIe except for nausea and epigastric pain both of which were fleeting in character. On two occasions the icteric index was 17.5 and the skin and scIerae showed sIight icterus which was not adequateIy expIained. The patient was discharged we11 on the thirteenth postoperative day. Two weeks after discharge he returned to the emergency ward compIaining of severe pain in the right upper abdomen associated with vomiting. He stated that the vomitus contained about one teaspoonfu1 of bright red blood. PhysicaI examination was negative, and after brief observation he was again discharged. One week Iater because he continued to compIain of epigastric pain, nausea, and of severa dark-coIored stooIs, he was readmitted to the hospita1. At this time physica examination reveaIed the foIIowing: palIor and dehydration, sIight epigastric tenderness, B.P. 80/45, T. 99.2, pulse 120, respirations 20. CIinicaI Pathology: urine negative, white bIood count 33,800, Hb. go (T.), red bIood count 6, IOO,OOO. The stoo1 was grossIy bIoody. On the day of admission he suddenIy vomited about a liter of bIoody materia1 and went into shock. He was put on a Sippy regime. Ten days after admission a partia1 gastrointestina1 series reveaIed marked pyIorospasm. The
* From the Surgical Service of the Beth IsraeI HospitaI, Boston.
568
NEW SERIES VOL.. XXVI,
No. 3
Hermanson
& Cabitt-Hematemesis
duodenal cap was spastic, irritabIe and irreguIar. The roentgenoIogist’s opinion was that the patient had a duodena1 uIcer, which, were it
FIG. I. View of whole liver showing tear.
extent
and course
A merican Journal
of Surgery 569
repeated hemorrhages. The examination reveaIed the esophagus to be normaI. Three days Iater, on the thirty-ninth postoperative day,
of
not for the recent history, couId be reconciled with the cIinica1 findings. He appeared we11 for another ten days, when he had a second severe hematemesis and again went into shock. He responded we11 to the usua1 treatment unti1 four days Iater. At this time, because of a recurrent massive hemorrhage from what was apparentIy a duodenal uIcer, he was subjected to Iaparotomy. ExpIoration revealed the Iiver to be norma except for adhesions over the upper surface. The stomach was opened, and both the stomach and duodenum were very carefuIIy examined. No uIcer, or any other cause for hematemesis was found. The stomach was cIosed and a jejunostomy was made for feeding, and the patient was transfused at the close of the operation. His convaIescence was stormy. He vomited a11 ora and jejunostomy feedings and, in addition, on the eighth postof operative day he vomited about 50 ounces bIoody fluid. He recovered after strenuous treatment and sIowIy improved during the foIlowing three weeks. The jejunostomy tube was then removed, after which he torerated a soft diet with onIy occasional attacks of vomiting. The vomitus was frequentIy bIood streaked. On the thirty-second postoperative day he twice vomited bIoody material, the tota voIume being about 50 ounces. On the thirty-sixth postoperative day he was esophagoscoped to determine whether or not any esophagear Iesion might be the cause of the
FIG. 2. Liver sectioned. Shows relation of tear toma and relation of hematoma to branches vein, bile ducts, gal1 bIadder, etc.
to hemaof portal
he suffered another massive hematemesis. He was again transfused and operated upon. Minute search reveared no obvious cause for hematemesis. The liver appeared the same as in the previous expIoration. Since the esophagus and the stomach were beIieved to be normal, it was assumed that the bIeeding came, perhaps, from a smaII uIcer on the posterior waI1 of the duodenum, which couId not be identified. The duodenum was therefore transected, both ends were cIosed and a posterior gastroenterostomy was made. At the concIusion of the operation his condition appeared fair, but he was transfused. On the fourth postoperative day he had another gastric hemorrhage, and from then on he went rapidIy down hiI1. The wound separated on the fifth postoperative day, and he expired two days later.
570
American Journal of Surgery
Hermanson
& Cabitt-Hematernesis
reveakd Postmortem examination the stomach to be normal except for the gastroenterostomy. The stump of the duodenum was dilated. No uker was found. The Iiver weighed 1320 gm. and was of normaI coIor and consistency. There was a healed rent IO cm. in Iength in the superior surface of the right Iobe of the Iiver. The rent was oblique corresponding in contour to the curve of the overIying rib. The scar passed beneath the annuIar Iigament and reached to the inferior surface of the Iiver in the region of the porta hepatis. Here it was found to extend into a weII-defined cavity about 4 cm. in diameter which was partIy fiIIed with blood cIot and communicated with a Iarge branch of the porta vein, and a greatIy distended bile duct. The gaII bIadder and biIiary ducts were fiIIed with clotted bIood mixed with biIe. SimiIar materia1 was found in the duodenum and intestines. COMMENT
WhiIe the greater number of cases of hematemesis are caused by lesions Iocated in the upper gastrointestina1 tract, there are extrinsic causes not infrequentIy encountered. In discussing the diagnostic significance of hematemesis Rivers and Wilbur1 state that go.5 per cent of a11 cases of hematemesis are due to intrinsic gastroduodena1 Iesions; 5.1 per cent are due to cirrhosis and spIenic anemia; and 4.5 per cent are due to a11 other causes, incIuding choIecystitis, hemophilia, hemoIytic icterus, and hemorrhagic purpura. In 2.2 per cent of the cases the cause is indeterminate. It does not seem to be generaIIy appreciated that disease or injury to the Iiver and biIe passage may give rise to hematemesis. This fact, however, is demonstrated by the foregoing case and others found in a search of the Iiterature. The mechanism of the hematemesis in such cases varies somewhat with the nature of the Iesion concerned. In our own case autopsy showed that the tear in the liver, which was at first thought to be superficial, extended deeply, and cut across not only a Iarge branch of the porta vein but aIso a sizabIe biIe duct. It is apparent that the
DECEMBER, ,934
bIood found its way from the tom vein into the open biIe duct, and thence into the hepatic and common biIe ducts, the gaI1 bIadder and duodenum. A few simiIar cases have been found in the Iiterature. ThorIakson and Hay2 report a case in which there was trauma to the upper quadrant pain, rigidity, tenderness and icterus. Much dark red bIood was passed by bowe1. Post-mortem examination discIosed partly heaIed wounds on the right Iobe of the liver. In the center of the right Iobe was found a Iarge area of necrotic tissue. The hepatic, cystic and common ducts, as we11 as the gaI1 bIadder, were fiIIed with bIood and, in addition, much oId bIood was found in the peritonea1 cavity. No hematemesis was noted in this case. JankeIson and White3 report a series of cases of hematemesis concomitant with 6 of gaII-bladder disease. They describe their own cases and cite 12 others from the Iiterature. In none of their cases, however, is it shown definiteIy that the bleeding came from the Iiver or biIe passages. They explain the hematemesis by erosion of vesseIs in the gaII-bIadder wall, fistuIa formation, or hemorrhagic infarction of the gaI1 bIadder. They aIso refer to Naunyn’s theory that toxins in the bIood coming from the infected gaI1 bIadder cause bIeeding from the mucosa of the stomach or duodenum. Of the 12 cases which they cite from the Iiterature, 3 are pertinent to this discussion. The first is a case reported by Schnyder4 of a man who had a Iarge intestina1 hemorrhage. Autopsy reveaIed a gaI1 bladder which had perforated and bled freeIy into the peritonea1 cavity and intestine. The second is a case of Lobstein’ of a sixty-five year oId woman with intestina1 hemorrhage. At operation a perforated gaI1 bIadder was found bIeeding into the peritonea1 cavity and into the Iumen of the gaI1 bladder. The third case by Heuser” is of a woman with a Iarge intestina1 hemorrhage and sIight jaundice. Operation showed hemorrhagic choIecystitis with
NEW SERIES Vor. XXVI,
No. 3
Hermanson
& Cabitt-Hematemesis
ukeration of the gal1 bIadder and many stones. Autopsy nine days Iater reveaIed a hemorrhagic infarct of the gaI1 bladder. NothnageP states that in hyperemia and inflammation of the Iiver bIood may be found in the biIe passages and the gaI1 bIadder. Quinquad8 cites a case of hemorrhagic cholangitis associated with bIood in the biIe ducts and intestines, resuIting in bIoody stooIs and hematemesis. FinaIIy, TayIorg reports a case of a man aged twenty-two who, after recovery from a severe gastric hemorrhage reveaIed at operation a hard mass, the size of a waInut, in the posterior waII of the duodenum. A gastroenterostomy was made. A month Iater the patient had another hemorrhage. Two months Iater a second operation reveaIed the duodena1 mass to be much Iarger. At necropsy a ruptured aneurysm of the hepatic artery communicating with the gaI1 bIadder was found.
A me&an
Journal
of Surgery
4
7I
SUMMARY I. A case of hematemesis due to trauma of the Iiver is reported. 2. The mechanism of the hemorrhage is described. 3. A brief review of the Iiterature is incIuded. REFERENCES I. RIVERS, A. B. and WILBUR, D. L. J. A. M. A., 98: 1629-1631 (May 7) 1932. 2. THORLAKSON, P. H. T., and HAY, A. W. Canad. M. A. J., 20: 593-598 (June) 1929. 3. JANKELSON,L. R., and WHITE, Q. W. New England J. Med., 205: 793-797 (Oct. 22) 1931. 4. SCHNYDER.Todliche GallenbIasebIutung in die freie BauchhohIe. Centrabl f. allgem. Path. u. Path. Anat., 26: 14, 1915. 5. LOBSTEIN. Quoted by Heuser. 6. HEUSER. Die blutende GaIIenbIase. Munch Med. Webs&., 72: 2007, 1925. 7. NOTHNAGEL. Encyclopedia of Practical Medicine, p. 521. 8. QUINQUAD.Les affections du foie. Paris, 1879. 9. TAYLOR, E. H. New England M. J., 208: 644 (March 3) 1933.
OF THE LIVER*
LOUIS HERMANSON,M.D. AND HENRY L. CABITT, M.D. BOSTON
H
EMATEMESIS
occurs with such frequency that its usua1 causes are common knowIedge. Ordinarily onIy Iesions invoIving the upper gastrointestina1 tract are considered in the differentia1 diagnosis of this symptom. To this practice may be ascribed occasiona errors in diagnosis. The purpose of this paper is to
report an unusua1 cause for hematemesis and to call attention to simiIar infrequent causes. CASE REPORT D. S. No. 17598. A sixteen-year-oId schooIboy was admitted on April 8, 1933 compIaining of pain in the right shouIder of three hours’ duration. He stated that whiIe running he feII against a curbstone, faIIing on the right upper abdomen and on the Iower right chest anteriorIy. This was folIowed immediateIy by pain in the right upper quadrant and in the tip of the right shouIder. The pain was constant, and associated with progressive weakness. Physical examination reveaIed an acuteIy III boy with marked paIIor of the skin and mucous membranes. The extremities were coId and cIammy. There was a red weIt extending across the Iower anterior portion of the right chest and the right upper quadrant. The abdomen was sIightIy distended and there was tenderness and spasm in the epigastrium and in the right upper quadrant. There was marked tenderness in the right costovertebra1 angIe. The temperature was IO~‘F., puIse 104, respirations 28, B.P. 120/70. The examination was otherwise negative. Clinical Pathology: The white bIood count was 21,000; Hb. go (T.); red bIood count 4,100,000. The urine contained a sIight trace of aIbumin and 30 red bIood ceIIs per high power fieId. Diagnoses of ruptured Iiver, ruptured right kidney, ruptured viscus, and intraperitonea1
hemorrhage were made. Because of the possibiIity of ruptured viscus, Iaparotomy was performed shortIy after admission. Under general anesthesia the abdomen was opened through a high right paramedian incision. ExpIoration reveaIed a Iarge amount of free bIood in the peritonea1 cavity. There was an obIique tear through the upper surface of the right Iobe of the Iiver corresponding in direction to that of the overIying rib. The tear was very superficia1 IateraIIy, but deep mediaIIy. There was edema of the gastrohepatic omentum. A sIight rupture of the Iower poIe of the right kidney with a moderate intracapsuIar hemorrhage was noted. The tear in the Iiver was packed with gauze and the abdomen was cIosed. ConvaIescence was not remarkabIe except for nausea and epigastric pain both of which were fleeting in character. On two occasions the icteric index was 17.5 and the skin and scIerae showed sIight icterus which was not adequateIy expIained. The patient was discharged we11 on the thirteenth postoperative day. Two weeks after discharge he returned to the emergency ward compIaining of severe pain in the right upper abdomen associated with vomiting. He stated that the vomitus contained about one teaspoonfu1 of bright red blood. PhysicaI examination was negative, and after brief observation he was again discharged. One week Iater because he continued to compIain of epigastric pain, nausea, and of severa dark-coIored stooIs, he was readmitted to the hospita1. At this time physica examination reveaIed the foIIowing: palIor and dehydration, sIight epigastric tenderness, B.P. 80/45, T. 99.2, pulse 120, respirations 20. CIinicaI Pathology: urine negative, white bIood count 33,800, Hb. go (T.), red bIood count 6, IOO,OOO. The stoo1 was grossIy bIoody. On the day of admission he suddenIy vomited about a liter of bIoody materia1 and went into shock. He was put on a Sippy regime. Ten days after admission a partia1 gastrointestina1 series reveaIed marked pyIorospasm. The
* From the Surgical Service of the Beth IsraeI HospitaI, Boston.
568
NEW SERIES VOL.. XXVI,
No. 3
Hermanson
& Cabitt-Hematemesis
duodenal cap was spastic, irritabIe and irreguIar. The roentgenoIogist’s opinion was that the patient had a duodena1 uIcer, which, were it
FIG. I. View of whole liver showing tear.
extent
and course
A merican Journal
of Surgery 569
repeated hemorrhages. The examination reveaIed the esophagus to be normaI. Three days Iater, on the thirty-ninth postoperative day,
of
not for the recent history, couId be reconciled with the cIinica1 findings. He appeared we11 for another ten days, when he had a second severe hematemesis and again went into shock. He responded we11 to the usua1 treatment unti1 four days Iater. At this time, because of a recurrent massive hemorrhage from what was apparentIy a duodenal uIcer, he was subjected to Iaparotomy. ExpIoration revealed the Iiver to be norma except for adhesions over the upper surface. The stomach was opened, and both the stomach and duodenum were very carefuIIy examined. No uIcer, or any other cause for hematemesis was found. The stomach was cIosed and a jejunostomy was made for feeding, and the patient was transfused at the close of the operation. His convaIescence was stormy. He vomited a11 ora and jejunostomy feedings and, in addition, on the eighth postof operative day he vomited about 50 ounces bIoody fluid. He recovered after strenuous treatment and sIowIy improved during the foIlowing three weeks. The jejunostomy tube was then removed, after which he torerated a soft diet with onIy occasional attacks of vomiting. The vomitus was frequentIy bIood streaked. On the thirty-second postoperative day he twice vomited bIoody material, the tota voIume being about 50 ounces. On the thirty-sixth postoperative day he was esophagoscoped to determine whether or not any esophagear Iesion might be the cause of the
FIG. 2. Liver sectioned. Shows relation of tear toma and relation of hematoma to branches vein, bile ducts, gal1 bIadder, etc.
to hemaof portal
he suffered another massive hematemesis. He was again transfused and operated upon. Minute search reveared no obvious cause for hematemesis. The liver appeared the same as in the previous expIoration. Since the esophagus and the stomach were beIieved to be normal, it was assumed that the bIeeding came, perhaps, from a smaII uIcer on the posterior waI1 of the duodenum, which couId not be identified. The duodenum was therefore transected, both ends were cIosed and a posterior gastroenterostomy was made. At the concIusion of the operation his condition appeared fair, but he was transfused. On the fourth postoperative day he had another gastric hemorrhage, and from then on he went rapidIy down hiI1. The wound separated on the fifth postoperative day, and he expired two days later.
570
American Journal of Surgery
Hermanson
& Cabitt-Hematernesis
reveakd Postmortem examination the stomach to be normal except for the gastroenterostomy. The stump of the duodenum was dilated. No uker was found. The Iiver weighed 1320 gm. and was of normaI coIor and consistency. There was a healed rent IO cm. in Iength in the superior surface of the right Iobe of the Iiver. The rent was oblique corresponding in contour to the curve of the overIying rib. The scar passed beneath the annuIar Iigament and reached to the inferior surface of the Iiver in the region of the porta hepatis. Here it was found to extend into a weII-defined cavity about 4 cm. in diameter which was partIy fiIIed with blood cIot and communicated with a Iarge branch of the porta vein, and a greatIy distended bile duct. The gaII bIadder and biIiary ducts were fiIIed with clotted bIood mixed with biIe. SimiIar materia1 was found in the duodenum and intestines. COMMENT
WhiIe the greater number of cases of hematemesis are caused by lesions Iocated in the upper gastrointestina1 tract, there are extrinsic causes not infrequentIy encountered. In discussing the diagnostic significance of hematemesis Rivers and Wilbur1 state that go.5 per cent of a11 cases of hematemesis are due to intrinsic gastroduodena1 Iesions; 5.1 per cent are due to cirrhosis and spIenic anemia; and 4.5 per cent are due to a11 other causes, incIuding choIecystitis, hemophilia, hemoIytic icterus, and hemorrhagic purpura. In 2.2 per cent of the cases the cause is indeterminate. It does not seem to be generaIIy appreciated that disease or injury to the Iiver and biIe passage may give rise to hematemesis. This fact, however, is demonstrated by the foregoing case and others found in a search of the Iiterature. The mechanism of the hematemesis in such cases varies somewhat with the nature of the Iesion concerned. In our own case autopsy showed that the tear in the liver, which was at first thought to be superficial, extended deeply, and cut across not only a Iarge branch of the porta vein but aIso a sizabIe biIe duct. It is apparent that the
DECEMBER, ,934
bIood found its way from the tom vein into the open biIe duct, and thence into the hepatic and common biIe ducts, the gaI1 bIadder and duodenum. A few simiIar cases have been found in the Iiterature. ThorIakson and Hay2 report a case in which there was trauma to the upper quadrant pain, rigidity, tenderness and icterus. Much dark red bIood was passed by bowe1. Post-mortem examination discIosed partly heaIed wounds on the right Iobe of the liver. In the center of the right Iobe was found a Iarge area of necrotic tissue. The hepatic, cystic and common ducts, as we11 as the gaI1 bIadder, were fiIIed with bIood and, in addition, much oId bIood was found in the peritonea1 cavity. No hematemesis was noted in this case. JankeIson and White3 report a series of cases of hematemesis concomitant with 6 of gaII-bladder disease. They describe their own cases and cite 12 others from the Iiterature. In none of their cases, however, is it shown definiteIy that the bleeding came from the Iiver or biIe passages. They explain the hematemesis by erosion of vesseIs in the gaII-bIadder wall, fistuIa formation, or hemorrhagic infarction of the gaI1 bIadder. They aIso refer to Naunyn’s theory that toxins in the bIood coming from the infected gaI1 bIadder cause bIeeding from the mucosa of the stomach or duodenum. Of the 12 cases which they cite from the Iiterature, 3 are pertinent to this discussion. The first is a case reported by Schnyder4 of a man who had a Iarge intestina1 hemorrhage. Autopsy reveaIed a gaI1 bladder which had perforated and bled freeIy into the peritonea1 cavity and intestine. The second is a case of Lobstein’ of a sixty-five year oId woman with intestina1 hemorrhage. At operation a perforated gaI1 bIadder was found bIeeding into the peritonea1 cavity and into the Iumen of the gaI1 bladder. The third case by Heuser” is of a woman with a Iarge intestina1 hemorrhage and sIight jaundice. Operation showed hemorrhagic choIecystitis with
NEW SERIES Vor. XXVI,
No. 3
Hermanson
& Cabitt-Hematemesis
ukeration of the gal1 bIadder and many stones. Autopsy nine days Iater reveaIed a hemorrhagic infarct of the gaI1 bladder. NothnageP states that in hyperemia and inflammation of the Iiver bIood may be found in the biIe passages and the gaI1 bIadder. Quinquad8 cites a case of hemorrhagic cholangitis associated with bIood in the biIe ducts and intestines, resuIting in bIoody stooIs and hematemesis. FinaIIy, TayIorg reports a case of a man aged twenty-two who, after recovery from a severe gastric hemorrhage reveaIed at operation a hard mass, the size of a waInut, in the posterior waII of the duodenum. A gastroenterostomy was made. A month Iater the patient had another hemorrhage. Two months Iater a second operation reveaIed the duodena1 mass to be much Iarger. At necropsy a ruptured aneurysm of the hepatic artery communicating with the gaI1 bIadder was found.
A me&an
Journal
of Surgery
4
7I
SUMMARY I. A case of hematemesis due to trauma of the Iiver is reported. 2. The mechanism of the hemorrhage is described. 3. A brief review of the Iiterature is incIuded. REFERENCES I. RIVERS, A. B. and WILBUR, D. L. J. A. M. A., 98: 1629-1631 (May 7) 1932. 2. THORLAKSON, P. H. T., and HAY, A. W. Canad. M. A. J., 20: 593-598 (June) 1929. 3. JANKELSON,L. R., and WHITE, Q. W. New England J. Med., 205: 793-797 (Oct. 22) 1931. 4. SCHNYDER.Todliche GallenbIasebIutung in die freie BauchhohIe. Centrabl f. allgem. Path. u. Path. Anat., 26: 14, 1915. 5. LOBSTEIN. Quoted by Heuser. 6. HEUSER. Die blutende GaIIenbIase. Munch Med. Webs&., 72: 2007, 1925. 7. NOTHNAGEL. Encyclopedia of Practical Medicine, p. 521. 8. QUINQUAD.Les affections du foie. Paris, 1879. 9. TAYLOR, E. H. New England M. J., 208: 644 (March 3) 1933.