Spontaneous hepatic haemorrhage: a review of pathogenesis, aetiology and treatment.

BACKGROUND: A 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. METHODS: A 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. RESULTS: After 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. CONCLUSION: A spontaneous hepatic haemorrhage is an acute presentation of a spectrum of conditions that requires early diagnosis and multidisciplinary management.

Prioritization of patients with rectal bleeding for urgent outpatient colonoscopy--a pilot study.

AIM: Rectal bleeding is a common symptom in general practice and may be associated with colorectal neoplasia. Waiting-lists for outpatient colonoscopies and first specialist appointments are long. The aim of our study was to determine the value of presenting signs and symptoms in prioritising patients with rectal bleeding for urgent colonoscopy. METHOD: Patients were asked to fill out a 'Bowel symptoms Assessment Questionnaire' at their first visit to a Colorectal Clinic. Patients were then assessed by clinicians who referred them for further investigations as appropriate. Factors from the questionnaire (e.g. age, family history, perianal symptoms, and so on) were analysed to assess correlation with colorectal cancer or neoplasia. These were analysed using logistic regression, SPSS Answertree and 2x2 tables. RESULTS: 105 patients completed the questionnaire. Thirty patients had colonoscopy/barium enema. Fifteen patients had colorectal cancer (CRC) or neoplasia detected. There was a significant increase in risk of developing CRC or neoplasia in patients above the age of 67 or if they had a positive family history of CRC or neoplasia. CONCLUSION: We conclude that patients with rectal bleeding, above the age of 67 or those with a positive family history are at a higher risk of neoplasia and should receive priority access to colonoscopy prior to first specialist assessment.

Is routine placement of surgical drains necessary after elective hepatectomy? Results from a single institution.

Routine drainage is no longer used after many major abdominal procedures. However, the role of routine surgical drainage after hepatic resection is unclear. Of the two randomized trials published, one concluded drainage is unnecessary after hepatectomy, and another concluded it could be used after major resections only. Between January 1999 and December 2003, 211 elective hepatic resections were performed by two surgeons at Auckland Hospital. Drains were used routinely by one surgeon (n = 126), while another routinely did not drain (n = 85). Patients undergoing a biliary reconstruction were not included in this analysis. Patient and clinical data were recorded prospectively, and no outcome analyses were performed until 2004. The demographic features were similar between the drained and non-drained groups. There were no differences in length of hospital stay (no drain, 7 +/- 0.8 days; drain, 7 +/- 0.9 days: P = not significant [NS]), in mortality (no drain, 1.2%; drain, 1.6%: P = NS), biliary fistula (no drain, zero cases; drain, two cases: P = NS), or overall complication rate (no drain, 50.5%; drain, 54.7%: P = NS). Both groups had similar rates of postoperative collection (no drain, four patients [5%]; drain, five patients [4%]: P = NS), and there was no difference in the use of percutaneous drainage of collections between the groups (no drain, four patients [5%]; drain, two patients [2%]: P = NS). Multivariate analysis showed that intraoperative blood loss of 2000 ml or greater (relative risk [RR], 1.57; 95% confidence interval [CI], 1.39-1.75; P < 0.01), number of segments resected (RR, 1.4; 95% CI, 1.21-1.89; P < 0.01), and presence of steatosis/fibrosis or cirrhosis (RR, 1.6; 95% CI, 1.01-2.1; P < 0.05) to be predictive of postoperative complications. The presence of a surgical drain was not predictive of complications. Routine surgical drainage after elective hepatectomy is not necessary.