What is the management approach for a patient with a subcapsular hematoma?

Management of Subcapsular Hematoma

The management of subcapsular hematoma should be guided primarily by the patient's hemodynamic status, with hemodynamically stable patients receiving conservative management and unstable patients requiring immediate intervention. 1

Assessment and Classification

• Subcapsular hematomas are collections of blood between an organ's parenchyma and its capsule, most commonly affecting the liver and kidneys 1
• Initial evaluation must include:
  • Hemodynamic status assessment (vital signs, shock indicators) 2, 1
  • Laboratory studies (hemoglobin, coagulation parameters, organ function tests) 1
  • Imaging to determine hematoma size and presence of active bleeding 1
• For liver subcapsular hematomas, classification follows the AAST scale:
  • Grade I: <10% surface area
  • Grade II: 10-50% surface area
  • Grade III: >50% surface area or expanding/ruptured 2, 1

Management Algorithm

For Hemodynamically Stable Patients (WSES Class I-III)

• Non-operative management (NOM) is the standard of care 2, 1
• Management includes:
  • Admission for close monitoring, preferably ICU for moderate to severe cases 1
  • Serial clinical evaluations and hemoglobin measurements 1
  • Bedside ultrasound or CT for monitoring hematoma size 1, 3
  • Correction of any coagulopathy 2, 1
  • Pain management 4

For Hemodynamically Unstable Patients (WSES Class IV)

• Immediate bleeding control procedures are required 2
• Options include:
  • Angiography with selective embolization for identifiable bleeding sources 1, 5
  • Surgical intervention if embolization fails or is unavailable 2, 1
  • Damage control surgery for exsanguinating patients 2

Intervention Indications

• Hemodynamic instability despite adequate resuscitation 2, 1
• Evidence of expanding hematoma or active bleeding 1
• Development of abdominal compartment syndrome 1
• Secondary infection of the hematoma 1, 6

Organ-Specific Considerations

Liver Subcapsular Hematoma

• Conservative management with serial imaging is recommended for large unruptured hematomas 1, 7
• Percutaneous drainage may be indicated for symptomatic or infected hematomas 1, 6
• For ruptured hematomas, angiographic embolization should be attempted before surgical intervention 1

Renal Subcapsular Hematoma

• Angiography and selective embolization are effective for controlling hemorrhage 5
• Total or partial embolization may be required, potentially resulting in functional loss of the affected kidney 5
• Consider underlying renal disease when planning management 5

Follow-up and Monitoring

• Serial imaging (ultrasound or CT) to monitor hematoma resolution 1
• Laboratory monitoring of organ function (liver enzymes, renal function) 1, 4
• Long-term follow-up to assess for delayed complications 1

Common Pitfalls and Caveats

• Delayed rupture can occur days after initial presentation, necessitating continued vigilance 1, 4
• Secondary complications may develop, including:
  • Abscesses or infection 1, 6
  • Pseudoaneurysms 1, 6
  • Pleural effusions 4
  • Organ dysfunction 1, 5
• For iatrogenic subcapsular hematomas (post-biopsy, post-PTBD), consider a three-step approach:
  1. Hepatic arteriography and selective embolization
  2. Pigtail catheter drainage
  3. Hepatic vein stenting if outflow obstruction occurs 6