Octreotide in the management of abdominal wall haematoma in a patient with liver cirrhosis

Abstract

Introduction: Spontaneous haematomas in the context of cirrhosis have been documented in the literature in numerous case reports. Management strategies described range from conservative management to radiological and/or surgical interventions. Our case outlines the complex management issues of a patient with Child–Pugh C cirrhosis, who presented with a spontaneous subcutaneous haematoma anterior to the rectus sheath. Our case is distinguishable from existing reports due to the use of an octreotide infusion, which may have contributed to haemostasis. Background: A literature review was conducted in order to source cases of spontaneous haematoma in patients with cirrhosis. The primary search strategy was through PubMed, utilising the MeSH terms cirrhosis AND haematoma which resulted in 301 articles. We narrowed our search based on articles that were accessible and written in English, and excluded cases with intracranial haematomas or haematomas directly attributable to procedures (e.g. endoscopic therapy, epidural catheterization or paracentesis). Although the 34 selected cases may be dissimilar with regards to the location of bleeding, they presented similar management issues. Of the 34 cases, 21 were managed conservatively, 6 underwent arterial embolisation or trans-catheter coiling, and 4 patients had interventional procedures (surgical exploration, liver transplant, fasciotomy and/or evacuation). Of the cases reviewed, only 35% survived their hospital admission. Conservative management resulted in a relatively lower survival rate (29%) compared with interventional management (50%). There are no documented cases in the literature of octreotide use in order to achieve haemostasis in patients with non-variceal haematomas in the context of cirrhosis. Case Description: This case focuses on the management issues of a 53- year-old patient with a background of Child–Pugh C cirrhosis secondary to alcohol use, who presented with a spontaneous abdominal haematoma. There was significant ongoing bleeding within the haematoma following admission to hospital resulting in initiation of a massive transfusion protocol. The patient required 14 units of packed red blood cells (pRBC), 6 units of fresh frozen plasma (FFP), 5 units of cryoprecipitate and daily vitamin K to maintain a haemoglobin level greater than 70 mg/dL during the first four days of admission. Concurrently, medical management of his liver disease was optimised (beta blockers, spironolactone and lactulose) and regular multidisciplinary team consultation (general surgery, vascular, acute pain service, intensive care team, interventional radiology and haematology) was obtained. In view of ongoing transfusion requirement, octreotide 50 μg/h continuous intravenous infusion was commenced on day 4 of admission. This correlated with a significant decrease in blood product requirement, with no further pRBC transfusion required for the next 7 days. The patient had two CT angiograms and a CT abdomen/pelvis to review haematoma size and potential sources of bleeding. A bleeding vessel suitable for embolisation could not be conclusively demonstrated. Imaging confirmed that the haematoma had developed outside the rectus sheath, thus reducing the likelihood of a self-tamponading effect. Definitive surgical management was performed on day 11 by the plastic surgery team who evacuated the haematoma and ligated perforators. Multiple wash outs and debridement were required, prior to the formation of a skin graft on day 30. Our patient was discharged on day 40 post hospital admission. Conclusion: Spontaneous haematoma in the context of liver cirrhosis poses a unique management challenge, with poor outcomes and limited treatment options. Our case demonstrates that octreotide may be useful in this situation by reducing transfusion requirement and contributing to haemostasis. The latter is supported by the fact that since the bleeding point in our case was located beyond the rectus sheath in the subcutaneous tissues, it is unlikely the tamponade effect seen in rectus sheath haematoma would have contributed to haemostasis. While further research is needed, octreotide may be considered as a potential treatment option or as a bridge to definitive therapy in the management of spontaneous haematomas in patients with cirrhosis. Show more