Clinical presentation and outcome of hepatic subcapsular fluid collections

Bile, blood or pus may rupture into or extend to the hepatic subcapsular space, but most descriptions in the literature are from isolated case reports. When fluid collections are limited by the size of the subcapsular space, they rarely present with abrupt symptoms and signs. We reviewed our experience with hepatic subcapsular fluid collections, including diagnostic studies and outcome.

Two radiologists independently assessed imaging database from computed tomography (CT) with the letter strings "subcapsule", "subcapsular", "liver" or "hepatic". Subcapsular fluid collection was defined as fluid deep in the liver capsule and superficial to the liver parenchyma without rupture into the peritoneum. The demographic data, clinical presentation, laboratory and imaging results, length of hospital stay, final diagnosis, and outcome were reviewed and recorded.

From January 2002 to December 2004, 60 patients (33 males, 27 females; age range, 4-92 years) were diagnosed by CT to have a subcapsular fluid accumulation in liver. Etiologies included traumatic hematoma in 10, tumor-related hematoma in 18, ruptured liver abscess in 20, biloma in 8, and 4 miscellaneous causes. CT typically showed a lenticular-shaped fluid collection compressing the liver parenchyma. The fluid accumulation was connected in over half the cases to an intrahepatic lesion with a visible tract. Conservative management was adequate in 32 patients, while 9 had surgery and 19 underwent either percutaneous drainage (by CT or ultrasound guidance) or transarterial therapy. Of the 60 patients, 49 (82%) survived the episode, including all 10 with traumatic hematoma. The shortest mean length of hospital stay was 7.8 +/- 6.7 days in the tumor-related hematoma group, and the longest was 50.7 +/- 41.7 days in the abscess group. The international normalized ratio for coagulation for those who died and those who survived was 1.8 +/- 1.4 and 1.4 +/- 0.2 respectively (p = 0.027).

If these fluid collections are limited in the subcapsular space, they are rarely associated with abrupt hemodynamic instability and usually not lethal. The only characteristic that differed significantly between those who died and those who survived was the international normalized ratio, meaning that good liver function and normal coagulation has the ability to recover from this dismal episode.