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Portal Vein Thrombosis After Percutaneous Liver Biopsy

Published:August 02, 2017DOI:https://doi.org/10.1016/j.cgh.2017.07.027
      Liver biopsy is often performed for evaluation of chronically elevated liver tests to aid in diagnosis and fibrosis staging; however, it is not without risk.
      • Rockey D.C.
      • Caldwell S.H.
      • Goodman Z.D.
      • et al.
      Liver biopsy.
      Commonly reported complications of liver biopsy include pain, occurring in up to 83% of patients,
      • Eisenberg E.
      • Konopniki M.
      • Veitsman E.
      • et al.
      Prevalence and characteristics of pain induced by percutaneous liver biopsy.
      bleeding in 18%–20% of patients, encompassing hemoperitoneum, intrahepatic hematoma, hemobilia, and hemothorax,
      • Rockey D.C.
      • Caldwell S.H.
      • Goodman Z.D.
      • et al.
      Liver biopsy.
      and iatrogenic puncture of another organ such as lung, kidney, colon, or gallbladder. Multiple rare complications from liver biopsy have been reported. The case described below highlights a unique complication of portal vein thrombosis after a percutaneous liver biopsy.
      A 64-year-old woman presented with 25 days of dull constant right upper quadrant abdominal pain that began 1 day after a percutaneous liver biopsy. Her history was significant for prior cholecystectomy as well as past sphincterotomy for reported sphincter of Oddi dysfunction. Her liver biopsy was performed for chronically elevated liver tests in a predominantly hepatocellular pattern (baseline aspartate aminotransferase, 30–50 IU/L [reference, 0–32 IU/L]; alanine aminotransferase, 30–50 IU/L [reference, 0–33 IU/L]; and alkaline phosphatase, 140–170 IU/L [reference, 35–105 IU/L]). Extensive work-up for etiology of her chronic hepatitis had been negative. She was not taking any known hepatotoxic medications. The biopsy showed mild chronic lobular hepatitis with stage 1 fibrosis. On presentation the physical exam was significant only for mild right upper quadrant and epigastric abdominal tenderness without rebound or guarding. The laboratory analysis was significant for worsening liver function tests (total bilirubin, 0.4 mg/dL; aspartate aminotransferase, 70 IU/L; alanine aminotransferase, 89 IU/L; alkaline phosphatase, 228 IU/L). An ultrasound of the liver showed no evidence of free fluid or hepatic hematoma. Computed tomography revealed a thrombus in the posterior branch of the right portal vein with geographic hypoattenuation of liver segments 5, 6, and 7 (Figure A, arrow). These findings were new when compared with pre-biopsy imaging. She had no history of past thrombus or hypercoagulability. The thrombus was thought to be a complication of recent liver biopsy. The patient was managed conservatively and did well, with return of her liver tests to baseline and resolution of pain.
      Rare complications of percutaneous liver biopsy include biliary peritonitis, sepsis and shock, bilious pleural effusion, pseudoaneurysm of intercostal artery, and fragmentation of biopsy needle.
      • Piccinino F.
      • Sagnelli E.
      • Pasquale G.
      • et al.
      Complications following percutaneous liver biopsy: a multicentre retrospective study on 68,276 biopsies.
      Patients may also react to the anesthetic given before biopsy. Although the mortality rate is between 0% and 0.4%,
      • Rockey D.C.
      • Caldwell S.H.
      • Goodman Z.D.
      • et al.
      Liver biopsy.
       these events can lead to additional testing, procedures, and hospitalizations. Most complications are noted within 24 hours of procedure.
      • Piccinino F.
      • Sagnelli E.
      • Pasquale G.
      • et al.
      Complications following percutaneous liver biopsy: a multicentre retrospective study on 68,276 biopsies.
      In this case, we suspect the likely cause of the thrombus was damage to a small branch of portal vein during biopsy because of the location of the thrombus and timing after biopsy. Conservative treatment seems most appropriate. This is a reported case of portal vein thrombus as a complication of liver biopsy. Because of how frequently percutaneous liver biopsies are performed, it is important to raise awareness of this potentially serious complication that may require specific testing.

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        • et al.
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        Complications following percutaneous liver biopsy: a multicentre retrospective study on 68,276 biopsies.
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