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1015
Case
Report
I Hepatic Subcapsular of Biliary Lithotripsy Frank
P. McGrath,1
Stephen
Hematoma:
H. Lee, Robert
G. Gibney,
and H. Joachim
Biliany extracomporeal shock-wave lithotnipsy (BESWL) is now widely available in North America and Europe and is becoming an increasingly common noninvasive means for treating symptomatic gallstones. To our knowledge, this is the first report of a hepatic subcapsular hematoma occurring after such treatment.
Case
Report
Clinical and sonographic of the
liver
features of a large subcapsular hematoma man within 24 hr of extracorlithotripsy for symptomatic gallstones. Prelitho-
developed
in a 49-year-old
poreal shock-wave tripsy
coagulation
factors
with
a second-generation
gen,
W. Germany).
the
shock-wave
were
normal.
lithotripter
An intercostal
beam
because
The
procedure
(Lithostar
approach of the
was
Plus,
[1
was
]
retrocostal
performed
Siemens,
used
position
Erlan-
to target of the
gall
bladder. Analgesia was required, and the patient was given IV fentanyl citrate 50 g and diazepam 2.5 mg in addition to transcutaneous electrical nerve stimulation. After 770 shocks over a period of 15 mm at 66% of the maximal focal pressure, the procedure was discontinued by the supervising radiologist because of development of excessive
pain
deep
to
the
intercostal
targeting
difficulty in visualizing the gallbladder. liver were normal at this time.
window
Findings
and
increasing
on sonography
of the
Twenty-four hours later, the patient was admitted with acute pain right upper quadrant. Sonography revealed a 15 x 1 1 x 6 cm
in the
hepatic
subcapsular
dropped from
collection
(Fig.
1).
The
1 60 to 1 40 g/l and an elevation
hemoglobin in alkaline
(140 U/I), total bilirubin (40 Mmol/I), and aspartate (201 U/I) levels occurred. The symptoms resolved conservative Received I
treatment, November
and 15, 1989;
All authors: Department
the
patient
accepted
of Radiology,
was
had
phosphatase
aminotransferase during
discharged.
December
level
3 days
An Unusual
of
Follow-up
sonography slight
decrease
2 weeks in size
and
2 months
of the
hematoma.
later
showed The
patient
organization remains
and well.
Complications as a result of the energy/trauma of BESWL with the newer second-generation lithotnipsy machines have been relatively minor [2-4]. The reported frequencies of these side effects vary [2, 4] and include biliary colic (33-54%), mild pancreatitis (1 -2%), transient microscopic hematumia (3-5%), and skin petechiae (1 4-80%). To date, over 250 patients with symptomatic gallstones have been treated at our institution without significant side effects. Malone et al. [1 ] reported no adverse effects in 22 patients in whom the intercostal approach was used for targeting and shock-wave delivery. A large penisplenic hematoma as a result of ESWL for urinary calculi has recently been reported by Lanctin et al. [5], who used the second-generation Siemens Lithostan. Left flank and shoulder tip pain developed in their patient some hours after an uneventful lithotnipsy session. In retrospect, it was felt that the shoulder tip pain was an important diagnostic sign suggesting the development of this complication. The overriding feature in our patient was the excessive pain deep to the targeting site that developed early during BESWL, which persisted despite relocating the intercostal position of the shock-wave head. We are aware of one other case of subcapsular hematoma after BESWL with the second-genoration Domnier HM-4 lithotmipsy unit (L. Greiner, personal communication). This patient also had experienced severe
14, 1989.
University of British Columbia and Vancouver
May 1990 0361 -803Xf90/1
Burhenne
Discussion
General Hospital, 855 W. 12th Ave., Vancouver,
Address reprint requests to H.J. Burhenne. AJR 154:1015-1016,
Complication
545-1015
© American
Roentgen
Ray Society
B.C. Canada V5Z 1M9.
McGRATH
1016
ET
AL.
AJA:154,
May 1990
Downloaded from www.ajronline.org by Univ Of California-San Diego on 06/05/15 from IP address 132.239.1.230. Copyright ARRS. For personal use only; all rights reserved
Fig. 1.-Sonograms Sonogram obtained
through right lobe of liver. before biliary extracorporeal shock-wavelithotripsy(BESWL)was normal (not shown). A, Sonogram obtained 24 hr after BESWL shows 15 x 11 x 6 cm subcapsular collection. B, Sonogram obtained 2 weeks later shows
organization.
deep pain during BESWL that had necessitated discontinuation of the treatment. The severity of soft-tissue damage from ESWL is directly related to the mean pressure at the focal point of the shock waves, the total number of shock waves administered, and the frequency with which shock waves are administered [2,
6]. It is important
to note that this complication
developed
after the first lithotmipsy treatment and only 770 shock waves at 66% of the maximum focal pressure had been given. (Most of our first-time BESWL patients receive more than 2000 shock waves at 70% of maximum focal pressure.) It is therefore of the utmost importance to have a supervising physician in attendance at all times during treatment, both to ensure accurate targeting and to monitor the patient’s response in an attempt to recognize any early signs that may indicate the development of a complication. Since preparing this manuscript, we have become aware of a case of fatal retropenitoneal hemorrhage that occurred after renal lithotnipsy with a Donnier machine [7].
REFERENCES
1. Malone DE, Rawat B, Fache JS, Quenville NF, Burhonne HJ. The intercostal pathway for biliary 1990:174:349-351
2. Sackmann gallbladder
oxtracorporoal
M, Oelius M, Sauerbruch stones:
the
first
175
shockwave
lithotripsy.
T, ot al. Shock-wave patients.
N EngI
J Med
Radiology
lithotripsy
of
1988:318:
393-397 3. Malone DE, Becker CD, Reich KO, Quenvillo NF, Burhonne HJ. Soft-tissue effects of biliary extracorporoal shockwavo lithotripsy in swine. Br J Radiol 1989;62:843-848 4. Rawat B, Fache JS, Malone DE, Burhenne HJ. Biliary lithotripsy without oral chomolitholysis: the Vancouver experience. In: Burhenno HJ, Paumgartner G, Ferrucci JT (eds.). Biliary lithotripsy, vol. 2. Chicago: Year Book Medical, 1990 5. Lanctin HP, Futter NG, McKay DE, Herringor A, Faucher A. Splenic injury with oxtracorporoal shock wave lithotripsy: case report. Lithotripsy Stone Dis 1989:1:308-310 6. Sauerbruch T, Delius M, Paumgartnor G. ot al. Fragmentation of gallstones by extracorporeal shock waves. N EngI J Med 1986:314:818-822 7. Stoller ML, Litt L, Salazar RG. Severe hemorrhage after extracorporoal shock-wave lithotripsy. Ann Intern Med 1989:111:612-613
1015
Case
Report
I Hepatic Subcapsular of Biliary Lithotripsy Frank
P. McGrath,1
Stephen
Hematoma:
H. Lee, Robert
G. Gibney,
and H. Joachim
Biliany extracomporeal shock-wave lithotnipsy (BESWL) is now widely available in North America and Europe and is becoming an increasingly common noninvasive means for treating symptomatic gallstones. To our knowledge, this is the first report of a hepatic subcapsular hematoma occurring after such treatment.
Case
Report
Clinical and sonographic of the
liver
features of a large subcapsular hematoma man within 24 hr of extracorlithotripsy for symptomatic gallstones. Prelitho-
developed
in a 49-year-old
poreal shock-wave tripsy
coagulation
factors
with
a second-generation
gen,
W. Germany).
the
shock-wave
were
normal.
lithotripter
An intercostal
beam
because
The
procedure
(Lithostar
approach of the
was
Plus,
[1
was
]
retrocostal
performed
Siemens,
used
position
Erlan-
to target of the
gall
bladder. Analgesia was required, and the patient was given IV fentanyl citrate 50 g and diazepam 2.5 mg in addition to transcutaneous electrical nerve stimulation. After 770 shocks over a period of 15 mm at 66% of the maximal focal pressure, the procedure was discontinued by the supervising radiologist because of development of excessive
pain
deep
to
the
intercostal
targeting
difficulty in visualizing the gallbladder. liver were normal at this time.
window
Findings
and
increasing
on sonography
of the
Twenty-four hours later, the patient was admitted with acute pain right upper quadrant. Sonography revealed a 15 x 1 1 x 6 cm
in the
hepatic
subcapsular
dropped from
collection
(Fig.
1).
The
1 60 to 1 40 g/l and an elevation
hemoglobin in alkaline
(140 U/I), total bilirubin (40 Mmol/I), and aspartate (201 U/I) levels occurred. The symptoms resolved conservative Received I
treatment, November
and 15, 1989;
All authors: Department
the
patient
accepted
of Radiology,
was
had
phosphatase
aminotransferase during
discharged.
December
level
3 days
An Unusual
of
Follow-up
sonography slight
decrease
2 weeks in size
and
2 months
of the
hematoma.
later
showed The
patient
organization remains
and well.
Complications as a result of the energy/trauma of BESWL with the newer second-generation lithotnipsy machines have been relatively minor [2-4]. The reported frequencies of these side effects vary [2, 4] and include biliary colic (33-54%), mild pancreatitis (1 -2%), transient microscopic hematumia (3-5%), and skin petechiae (1 4-80%). To date, over 250 patients with symptomatic gallstones have been treated at our institution without significant side effects. Malone et al. [1 ] reported no adverse effects in 22 patients in whom the intercostal approach was used for targeting and shock-wave delivery. A large penisplenic hematoma as a result of ESWL for urinary calculi has recently been reported by Lanctin et al. [5], who used the second-generation Siemens Lithostan. Left flank and shoulder tip pain developed in their patient some hours after an uneventful lithotnipsy session. In retrospect, it was felt that the shoulder tip pain was an important diagnostic sign suggesting the development of this complication. The overriding feature in our patient was the excessive pain deep to the targeting site that developed early during BESWL, which persisted despite relocating the intercostal position of the shock-wave head. We are aware of one other case of subcapsular hematoma after BESWL with the second-genoration Domnier HM-4 lithotmipsy unit (L. Greiner, personal communication). This patient also had experienced severe
14, 1989.
University of British Columbia and Vancouver
May 1990 0361 -803Xf90/1
Burhenne
Discussion
General Hospital, 855 W. 12th Ave., Vancouver,
Address reprint requests to H.J. Burhenne. AJR 154:1015-1016,
Complication
545-1015
© American
Roentgen
Ray Society
B.C. Canada V5Z 1M9.
McGRATH
1016
ET
AL.
AJA:154,
May 1990
Downloaded from www.ajronline.org by Univ Of California-San Diego on 06/05/15 from IP address 132.239.1.230. Copyright ARRS. For personal use only; all rights reserved
Fig. 1.-Sonograms Sonogram obtained
through right lobe of liver. before biliary extracorporeal shock-wavelithotripsy(BESWL)was normal (not shown). A, Sonogram obtained 24 hr after BESWL shows 15 x 11 x 6 cm subcapsular collection. B, Sonogram obtained 2 weeks later shows
organization.
deep pain during BESWL that had necessitated discontinuation of the treatment. The severity of soft-tissue damage from ESWL is directly related to the mean pressure at the focal point of the shock waves, the total number of shock waves administered, and the frequency with which shock waves are administered [2,
6]. It is important
to note that this complication
developed
after the first lithotmipsy treatment and only 770 shock waves at 66% of the maximum focal pressure had been given. (Most of our first-time BESWL patients receive more than 2000 shock waves at 70% of maximum focal pressure.) It is therefore of the utmost importance to have a supervising physician in attendance at all times during treatment, both to ensure accurate targeting and to monitor the patient’s response in an attempt to recognize any early signs that may indicate the development of a complication. Since preparing this manuscript, we have become aware of a case of fatal retropenitoneal hemorrhage that occurred after renal lithotnipsy with a Donnier machine [7].
REFERENCES
1. Malone DE, Rawat B, Fache JS, Quenville NF, Burhonne HJ. The intercostal pathway for biliary 1990:174:349-351
2. Sackmann gallbladder
oxtracorporoal
M, Oelius M, Sauerbruch stones:
the
first
175
shockwave
lithotripsy.
T, ot al. Shock-wave patients.
N EngI
J Med
Radiology
lithotripsy
of
1988:318:
393-397 3. Malone DE, Becker CD, Reich KO, Quenvillo NF, Burhonne HJ. Soft-tissue effects of biliary extracorporoal shockwavo lithotripsy in swine. Br J Radiol 1989;62:843-848 4. Rawat B, Fache JS, Malone DE, Burhenne HJ. Biliary lithotripsy without oral chomolitholysis: the Vancouver experience. In: Burhenno HJ, Paumgartner G, Ferrucci JT (eds.). Biliary lithotripsy, vol. 2. Chicago: Year Book Medical, 1990 5. Lanctin HP, Futter NG, McKay DE, Herringor A, Faucher A. Splenic injury with oxtracorporoal shock wave lithotripsy: case report. Lithotripsy Stone Dis 1989:1:308-310 6. Sauerbruch T, Delius M, Paumgartnor G. ot al. Fragmentation of gallstones by extracorporeal shock waves. N EngI J Med 1986:314:818-822 7. Stoller ML, Litt L, Salazar RG. Severe hemorrhage after extracorporoal shock-wave lithotripsy. Ann Intern Med 1989:111:612-613
