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BackgroundA spontaneous hepatic haemorrhage (SHH) is a rare condition that presents acutely to both hepatobiliary and general surgeons. Management of the condition is challenging because of the emergent presentation requiring immediate intervention, the presence of underlying chronic liver disease and the multiple potential underlying aetiological conditions.MethodsA literature search on a spontaneous hepatic haemorrhage was instituted on Medline (1966–2014), Cochrane Register of Controlled Trials, EMBASE (1947–2014), PubMed, Web of Science and Google Scholar. The specific topics of interest were causes – including rare causes, pathophysiological mechanisms and management options. A narrative review was planned from the outset.ResultsAfter 1546 abstracts were reviewed, 74 studies were chosen for inclusion. Hepatocellular carcinoma (HCC) is the commonest cause of a spontaneous haemorrhage with 10% of HCC presenting with bleeding. Other causes are benign hepatic lesions (hemangioma, adenoma, focal nodular hyperplasia, nodular regenerative hyperplasia, biliary cystadenoma and angiomyelolipoma), malignant hepatic tumours (angiosarcoma, haemangioendothelioma, hepatoblastoma and rhabdoid sarcoma), peliosis hepatis, amyloid, systemic lupus erythematosis, polyarteritis nodosa, HELLP syndrome and acute fatty liver of pregnancy. Treatment practice emphasizes arterial embolization to obtain haemostasis with a hepatectomy reserved for tumour bearing patients after staging and assessment of liver function.ConclusionA spontaneous hepatic haemorrhage is an acute presentation of a spectrum of conditions that requires early diagnosis and multidisciplinary management.

A 2.5-year-old boy with known myotubular myopathy (Spiro-Shy-Gonatas syndrome) and gonadorelin intake 9 months ante-mortem was found dead in his bed at home. At autopsy a ruptured subcapsular haematoma of the liver with resulting haemoperitoneum (600 ml) was found. Both lobes of the liver showed numerous circular blood foci

Myocardial infarction ( MI) typically presents with chest pain, dyspnoea and pain in the left arm. In some cases, syncope may ensue and the patients can have blunt trauma to the abdomen, chest or head, which may be overlooked by the doctors and the patient, with more concern focusing on infarction alone. Moreover, signs of trauma may not appear until late in the course of hospitalisation. The patient reported on here had abdominal trauma following a syncopic event, resulting from an inferoposterior MI. Administration of thrombolytic treatment led to a hepatic haemorrhage. This life-threatening complication might have been prevented by a bedside ultrasonography performed by an emergency medicine doctor. This effective use of time can be remembered as ''time is muscle''.

Perihepatic packing was used in 25 of 197 (12.7%) patients presenting with liver trauma to westmead hospital over an 8 year period. Packing was used either to provide temporary haemostasis prior to transfer or as part of a definitive treatment plan at this hospital. Thirteen patients were packed prior to transfer. Only two were unstable on arrival, one of whom died. They were compared with 18 ‘comparison’ patients with liver injuries of similar severity. In this group 10 were unstable on arrival (p= 0.027). Nine of whom died (p= 0.015). Packing was used as part of a definitive treatment plan at westmead on 17 occasions. Four patients were coagulopathic and five had also been packed prior to arrival. Eight of this group died. Packing is a convenient and safe way of controlling major hepatic haemorrhage prior to transfer to a tertiary referral centre. It may also be part of a definitive treatment plan to control hepatic bleeding especially as many patients arrive with a coagulopathy or develop a coagulopathy during the course of surgery to control bleeding. Packing will control haemorrhage until the coagulopathy has been corrected.