Major bleeding after percutaneous ultrasound guided liver interventions. Role of US and CEUS in the emergency diagnosis

Background and aim: Bleeding after percutaneous echoguided interventions in the liver is a rare event, occuring in 1 – 2 percent of cases. The aim of this study was to assess the diagnostic accuracy of US and CEUS in major bleeding after percutaneous interventions.

Material and methods: Between 2008 and 2013 we have performed 1800 liver biopsies, 185 RFA, 400 PEI sessions and 80 liver abscess treatments and 140 percutaneous biliary drainages. For all procedures a PLT over 80.000/mmc and an INR below 1.3 was required. After the intervention the patients were followed-up for 24 hours (clinically, lab test and ultrasound). In cases of significant bleeding a CEUS examination was performed.

Results: The total rate of bleeding for liver biopsy, PEI, RFA, and drainage procedures was 0.66%, 0.25%, 1.62% and 0.46% respectively. Among them 0.22%, 0%, 0.54%, 0% and 0% respectively had a significant bleeding, which required blood transfusion (3 patients) or open surgery (2 patients). The rate of significant bleeding was higher for liver biopsy performed for diffuse hepathopaties than for liver tumors (0.33% vs. 0.11%, p < 0.05). The US signs in case of major bleeding (5 patients) were intrahepatic haematoma ± large intraperitoneal fluid collection. CEUS was performed in 4 patients and was able to better deliniate the intrahepatic haematoma (4 patients) and to demonstrate the active bleeding (1 patient).

Conclusions: Significant bleeding after percutaneous echoguided interventions in the liver is a rare event occuring in less then 2% of cases. Ultrasound is the method of choice to certify the bleeding and to assess it's severity. CEUS is superior to US in to assessing the size and shape of the intrahepatic haematoma and the character of bleeding (active or inactive).