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A spontaneous hepatic haemorrhage (SHH) is a rare condition that results from a breach in the hepatic parenchyma that occurs without an external cause. It is an acute surgical emergency as it results in intra-abdominal bleeding that, if untreated, will progress to haemorrhagic shock and death. The clinical presentation is often non-specific but emergent, and rapid diagnosis and treatment is required, often involving a number of services including interventional radiology, hepatology and surgery. SHH is a rare event most commonly caused by HCC and hepatic adenoma although there are numerous other causative lesions including all recognized benign and malignant hepatic tumours including metastatic cancer. The mechanism of spontaneous bleeding remains unclear but there is evidence for compromised vascular integrity at least in patients with HCC and the incidence of the condition in patients with connective tissue diseases. A diagnosis of SHH is based on a clinical index of suspicion in patients with a known underlying condition. However, this is not always as straightforward as SHH is a rare complication in patients with connective tissue disease. Spontaneous hepatic haemorrhage is one of acute abdominal emergency case with high morbidity and mortality rate. Emergency operation plays an important role in managing this case.

Peliosis hepatis is an uncommon condition of unknown origin characterized by multiple blood-filled cystic spaces of varying size, focally or diffusely distributed in the liver parenchyma. Spontaneous haemorrhage is a significant complication with a high rate of mortality. We report the case of a massive spontaneous hepatic haemorrhage due to peliosis hepatis in a body builder, who had taken under-the-counter anabolic-androgenic steroids (AAS) for the previous 15 years. Our patient was admitted with a 6-hour history of right upper quadrant abdominal pain. Radiological investigations showed a large haematoma and small hypodense foci in the right lobe of the liver, the largest communicating with the haematoma. By laparotomy, the bleeding peliotic cavity was localized in the posterior aspect of the eighth hepatic segment. The definitive haemostasis was obtained after repeated laparotomy using radiofrequency-induced thermo-coagulation of the peliotic cavity. Histology confirmed the presence of peliosis hepatis. Radiofrequency is a potential treatment for a cataclysmic hepatic haemorrhage in peliosis hepatis. To our knowledge, haemostasis by radiofrequency of a bleeding peliotic lesion has not yet been described.

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

Innate resistance of Javanese thin-tailed sheep to Fasciola gigantica was investigated in animals infected with single doses of 150 or 500 metacercariae and killed 4, 8, 12 or 16 weeks after infection. Infected and non-infected sheep had similar values for packed cell volume, mean corpuscular volume, mean corpuscular haemoglobin concentration, serum glutamate dehydrogense, serum gamma glutamyl transferase and serum aspartate transferase throughout the trial, except for one animal infected with 500 metacercariae from which the highest recovery of flukes (55) was made. This animal developed pathologically altered values from 12 weeks post infection, coincident with the period of greatest hepatic haemorrhage and destruction of hepatic tissue by migrating flukes and their entry into bile ducts. However, values were altered much less than those reported in other sheep given as few as 200 metacercaria of F. gigantica. Both susceptibility to infection with F. gigantica, as indicated by percentage take of metacercariae and the severity of pathological changes were low in this study in comparison with reports involving other breeds of sheep infected with this parasite. These findings support the conclusion that Javanese thin-tailed sheep have a high innate resistance to F. gigantica.

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''.

A 79-year-old woman presented to the accident and emergency department with a short history of central chest pain radiating to the arm and epigastrum, associated with vomiting. There was no history of haematemesis and no recent change of bowel habit or melaena. She had a myocardial infarction 4 months previously and had a metal prosthetic mitral valve replacement for which she was anticoagulated with warfarin, maintaining an INR between 2.5– 3.5. On examination she appeared pale, but there were no other abnormal findings; the liver was not enlarged or tender.

We report the case of a 38-year-old male victim of a motorcycle accident who presented to the emergency department with a blood pressure of 90 mmHg/palpable and a haemoglobin of 6 gm dl-1. An exploratory laparotomy revealed a large liver laceration and profound haemorrhage. Liver packing was employed to prevent patient mortality in the face of an exsanguinating haemorrhage and multiple transfusions. The patient made an uneventful postoperative recovery. This case reinforces the indications, potential complications, and importance of liver packing in this type of grave clinical picture.

Haemorrhagic livers were observed in male white rock chicks of one to four weeks old, that were fed diets supplemented with 50 per cent rapeseed meal and 50 per cent rapeseed full-fat seeds. The haemorrhagic lesions were comparable to those of the laying hens except for the absence of fatty degeneration. There were no substantial fibrotic lesions. Multifocal or solitary hepatocytic necrosis was observed around the haemorrhagic lesions, although the necrotic foci did not always accompany the haemorrhage. The reticulum only of the necrotic and haemorrhagic lesions was not demonstrated with silver strain. Association of hepatocytic necrosis with liver haemorrhage and absence of argyrophilic fibres suggested that the hepatocytic necrosis was the primary contributory factor for the development of the hepatic haemorrhage.

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.