What are the immediate considerations for an elderly female with a history of cervical and endometrial adenocarcinoma, who presents with right groin, leg, and knee pain four days after a liver biopsy with fiducial marker placement for a hepatic lesion?

Immediate Differential Diagnosis: Post-Liver Biopsy Right Lower Extremity Pain

You must urgently rule out retroperitoneal hemorrhage with femoral nerve compression or vascular injury, as this represents a life-threatening complication that can occur after liver biopsy and presents with groin and leg pain. 1, 2

Critical Immediate Considerations

Life-Threatening Complications to Exclude First

Hemorrhagic complications are your primary concern, as bleeding is the most common serious complication after liver biopsy, occurring in approximately 0.5% of cases 1:

• Retroperitoneal hemorrhage can track inferiorly and compress the femoral nerve or psoas muscle, causing referred pain to the groin, leg, and knee 1, 2
• Intraperitoneal hemorrhage occurs in 0.032-0.7% of cases and can present with referred pain patterns 1
• Severe bleeding can occur up to one week after the procedure, possibly related to premature clot dissolution 2

Immediate assessment must include:

• Vital signs for tachycardia and hypotension (critical indicators of blood loss) 2
• Hemoglobin level to detect significant drop 2
• Abdominal examination for distension, tenderness, or peritoneal signs 2, 3
• Assessment for right shoulder pain (diaphragmatic irritation from blood) 3

Fiducial Marker-Specific Complications

Fiducial marker migration is a documented but rare complication that you cannot ignore in this patient 4:

• The marker can migrate through hepatic veins to the inferior vena cava or right atrium 4
• Migration can cause vascular injury or thrombosis affecting lower extremity venous return 4
• While the reported case involved cardiac migration, vascular injury along the iliac or femoral vessels could explain lower extremity symptoms 4

Other Post-Biopsy Complications Causing Pain

Organ perforation can occur during liver biopsy and may present with delayed symptoms 1:

• Perforation of adjacent structures (gallbladder, colon, kidney) occurs rarely but can cause referred pain 1
• Bile peritonitis can develop, especially given her hepatic malignancy 1
• Infection occurs in approximately 0.1% of cases and can present 4 days post-procedure 1

Diagnostic Workup Algorithm

Immediate (Within 1 Hour)

1. Vital signs every 15 minutes looking for hemodynamic instability 2, 3
2. Complete blood count with comparison to pre-biopsy hemoglobin 2
3. Coagulation studies (PT/INR, aPTT, platelets) 2
4. Abdominal and pelvic CT with IV contrast to evaluate for:
   • Retroperitoneal or intraperitoneal hemorrhage 1, 2
   • Fiducial marker position 4
   • Hematoma formation 1
   • Organ perforation or bile leak 1

If Initial Workup Negative

1. Lower extremity vascular ultrasound to exclude deep vein thrombosis (DVT) from hypercoagulability related to malignancy or procedural trauma 4
2. MRI of lumbar spine and pelvis if neurologic compression suspected and CT non-diagnostic
3. Ultrasound of biopsy site can detect intra-hepatic and perihepatic bleeding in 18-20% of patients 2

Management Priorities

If Hemorrhage Identified

Immediate resuscitation 2:

• Large-caliber IV access (two lines)
• 500 mL 0.9% saline bolus if hypotensive or tachycardic 2, 3
• Type and cross-match for blood products 2
• Angiographic embolization or surgery for ongoing blood loss 2

If Fiducial Migration Suspected

• Immediate imaging to locate marker 4
• Interventional radiology or cardiology consultation for potential retrieval 4
• The reported case successfully retrieved a migrated coil via jugular approach with EN Snare system 4

If Infection Suspected

• Blood cultures and broad-spectrum antibiotics if fever, leukocytosis, or peritoneal signs present 5, 1

Critical Pitfalls to Avoid

Do not dismiss this as simple musculoskeletal pain - the 4-day timeline falls within the window for delayed hemorrhage (up to 1 week post-procedure) 2. The British Society of Gastroenterology explicitly states patients should seek medical attention when pain persists beyond a few days despite painkillers 5.

Do not delay imaging - mortality from bleeding complications, while rare (0.009-0.33%), is preventable with early recognition 1, 2. Most severe hemorrhage is evident within 2-4 hours, but this patient is presenting at 4 days, which represents the delayed presentation pattern 2.

Consider her cancer history - patients with malignancy have increased bleeding risk after liver biopsy 6, 7, and her metastatic disease increases thrombotic risk that could cause DVT presenting as leg pain.

Remember the fiducial markers - this is not a standard liver biopsy; the placement of fiducial markers adds unique vascular injury and migration risks that most clinicians may not immediately consider 4.