Hepatic Compartment Syndrome Induced by Subcapsular Hematoma following Percutaneous Transhepatic Gallbladder...

Hepatic compartment syndrome (HCS) is a rare but potentially fatal condition caused by acute elevation of intrahepatic pressure, most often secondary to a subcapsular hematoma. Iatrogenic cases, particularly after percutaneous hepatobiliary interventions, have been only sporadically reported. We describe HCS following percutaneous transhepatic gallbladder drainage (PTGBD) complicated by a subcapsular hepatic hematoma.

A 49-year-old man underwent PTGBD for acute cholecystitis at the referring hospital. The catheter dislodged, and repeated attempts at re-placement over a guidewire failed, leaving the tip within the hepatic subcapsular space. The following day, he developed worsening abdominal pain, and CT revealed a massive right hepatic subcapsular hematoma. He was urgently transferred to our hospital. Contrast-enhanced CT demonstrated active extravasation, prompting emergency interventional radiology. Hepatic arteriography showed hepatofugal flow in the portal venous system, confirming HCS caused by intraparenchymal hypertension due to subcapsular compression. Decompression was achieved by placing a drain into the hematoma via the original PTGBD tract, followed by selective hepatic arterial embolization. Peak serum aspartate aminotransferase and alanine aminotransferase levels reached 9873 and 7385 U/L, respectively, before gradually declining. The hematoma caused compression of the inferior vena cava, intra-abdominal hypertension, and secondary acute kidney injury with pulmonary edema, requiring temporary renal replacement therapy. The hematoma progressively regressed with restored hepatic perfusion. Renal replacement therapy was discontinued prior to transfer, the drain was removed on day 24, and the patient was transferred for rehabilitation on day 34.

Early recognition of HCS and prompt decompression are essential to prevent irreversible hepatic and multiorgan injury.