What is the management and treatment for a subcapsular hematoma?

Management of Subcapsular Hematoma

Conservative management with close hemodynamic monitoring is the recommended approach for most subcapsular hematomas, with intervention reserved for cases with hemodynamic instability or specific complications.

Assessment and Classification

• Subcapsular hematomas are collections of blood between the organ parenchyma and its capsule, most commonly affecting the liver and kidneys 1, 2
• Assessment should include evaluation of hemodynamic status, hematoma size, underlying cause, and presence of active bleeding 1
• For liver subcapsular hematomas, the AAST liver injury scale helps classify severity:
  • Grade I: Subcapsular hematoma <10% surface area
  • Grade II: Subcapsular hematoma 10-50% surface area
  • Grade III: Subcapsular hematoma >50% surface area or expanding/ruptured 1

Management Approach

Conservative Management

• For hemodynamically stable patients with subcapsular hematomas, non-operative management (NOM) is the standard of care 1
• Conservative management includes:
  • Serial clinical evaluation and hemoglobin measurement 1
  • Bedside ultrasound for monitoring hematoma size 1
  • ICU admission for moderate to severe cases for close monitoring 1
  • Correction of coagulopathy if present 1
  • Blood transfusion as needed to maintain hemodynamic stability 3, 4

Indications for Intervention

• Hemodynamic instability despite resuscitation efforts 1
• Expanding hematoma with signs of impending rupture 1
• Evidence of ongoing bleeding 1, 2
• Development of abdominal compartment syndrome 1
• Secondary infection of the hematoma 1

Intervention Options

• Angiography with embolization:

  • First-line intervention for active bleeding in hemodynamically stable patients 1, 2
  • Can be safely repeated if needed 1
  • May result in some functional loss of the affected organ, particularly in patients with underlying organ disease 2

• Percutaneous drainage:

  • Indicated for symptomatic or infected bilomas/hematomas 1
  • Can be performed under ultrasound or CT guidance 1, 2

• Surgical management:

  • Reserved for hemodynamically unstable patients with active bleeding not controlled by embolization 1
  • Options include hematoma evacuation, repair of bleeding vessels, or partial organ resection in severe cases 1, 3
  • Laparoscopic exploration may be considered in selected cases to avoid extensive laparotomy 5

Organ-Specific Considerations

Liver Subcapsular Hematoma

• Most common in trauma but can occur with HELLP syndrome in pregnancy 3, 4
• Conservative management is successful in 84-85% of cases 3
• Complications include rupture, infection, and biliary complications (bile leak, biloma) 1
• For large subcapsular hematomas without rupture, close monitoring with serial imaging is recommended 1

Renal Subcapsular Hematoma

• May occur after procedures (biopsy, nephrostomy) or with underlying conditions like pyelonephritis 2, 6
• Diffuse cortical hemorrhage may be seen in some cases, caused by laceration of transcortical capsular arteries 2
• Embolization is effective for controlling hemorrhage but may compromise renal function, especially in patients with underlying renal disease 2

Follow-up and Monitoring

• Serial imaging (ultrasound or CT) to monitor hematoma resolution 1
• Laboratory monitoring of organ function (liver enzymes, renal function) 1
• Long-term follow-up to assess for delayed complications such as pseudoaneurysm formation 1

Common Pitfalls and Caveats

• Delayed rupture can occur days after initial presentation, necessitating continued vigilance even when patients appear stable 1, 3
• Underlying conditions (coagulopathy, pregnancy-related complications) must be addressed concurrently 3, 4
• Patients with subcapsular hematomas may develop secondary complications including abscesses, pseudoaneurysms, and organ dysfunction 1
• In pregnancy-related cases, subsequent pregnancies carry risk of recurrence and should be closely monitored 3