What is the recommended management for a large hepatic hematoma measuring approximately 12.5 × 8.2 cm?

Management of Large Hepatic Hematoma (12.5 × 8.2 cm)

Conservative non-operative management with close monitoring is the recommended initial approach for this large hepatic hematoma, reserving interventional procedures for hemodynamic instability, expanding hematoma, or development of complications. 1, 2

Initial Assessment and Stabilization

Immediate hemodynamic assessment is critical. Determine if the patient is hemodynamically stable (maintaining adequate blood pressure without ongoing resuscitation requirements). 1, 2

• For hemodynamically stable patients: Proceed with conservative management and serial monitoring 1, 2
• For hemodynamically unstable patients: Consider angiography with embolization as first-line intervention if arterial bleeding is identified on CT; operative management is indicated only if the patient fails to respond to resuscitation 1, 2

Diagnostic Imaging

Contrast-enhanced CT is the gold standard for evaluating hepatic hematomas and should be obtained immediately if not already done. 1, 2

• Look specifically for active arterial extravasation (contrast blush), which indicates ongoing bleeding requiring intervention 1, 2
• Ultrasound can be used for follow-up monitoring to detect debris, wall thickening, or changes in hematoma size 1
• MRI shows heterogeneous hyperintensity on both T1- and T2-weighted sequences in hemorrhagic lesions, though this is not necessary for acute management 1

Conservative Management Protocol

Admit to intensive care unit for close monitoring given the large size (>8 cm) of this hematoma. 2, 3

Monitoring Requirements:

• Serial clinical examinations every 4-6 hours initially, assessing for worsening abdominal pain, peritoneal signs, or hemodynamic changes 1, 2
• Serial hemoglobin/hematocrit every 6-8 hours for the first 24-48 hours, then daily 1, 3
• Liver function tests (AST, ALT, bilirubin, alkaline phosphatase) daily to detect hepatic dysfunction or biliary complications 1, 2
• Coagulation parameters (PT/INR, aPTT, fibrinogen, platelet count) to guide transfusion needs 1

Supportive Care:

• Maintain adequate intravascular volume with crystalloid resuscitation targeting mean arterial pressure 50-60 mmHg minimum 3
• Correct coagulopathy aggressively: Maintain fibrinogen >1.5 g/L, platelets >75 × 10⁹/L, and PT/aPTT <1.5 times normal 1
• Start enteral feeding as soon as tolerated to prevent complications and support healing 1, 2, 3
• Avoid anticoagulants and antiplatelet agents during the acute phase; if patient was on these medications, reverse carefully based on bleeding risk 1

Indications for Intervention

Angiography with embolization should be performed if:

• Active arterial bleeding (contrast extravasation) is seen on CT scan 1, 2
• Hemoglobin drops >2 g/dL despite transfusion 1
• Development of pseudoaneurysm on follow-up imaging 1
• Hemodynamic instability develops despite adequate resuscitation 1, 2

Percutaneous drainage is indicated for:

• Symptomatic or enlarging hematoma causing mass effect 1, 2, 3
• Infected hematoma (fever, leukocytosis, imaging findings of abscess formation) 1, 2, 3
• Associated biloma that is symptomatic or infected 1, 2, 3

Operative management is reserved for:

• Hemodynamic instability unresponsive to resuscitation and angioembolization 1, 2
• Hematoma rupture with peritonitis 1
• Large areas of devitalized liver tissue requiring debridement (only in delayed setting, not acutely) 1, 2

Management of Complications

Monitor closely for these specific complications:

Delayed Bleeding (occurs in 1.7-5.9% of cases):

• Most cases can be managed with angioembolization rather than surgery 1
• Pseudoaneurysm should be treated with embolization even if asymptomatic due to high rupture risk 1

Biliary Complications (incidence 2.8-30%):

• Biloma: Most regress spontaneously; drain if enlarging, symptomatic, or infected 1, 2, 3
• Bile leak: Combine percutaneous drainage with ERCP and biliary stent placement 1, 2, 3
• Hemobilia: Presents with melena or hematemesis; treat with angioembolization 1

Abscess Formation (0.6-7% incidence):

• Percutaneous drainage is first-line treatment with high success rates 1, 2, 3
• Add broad-spectrum antibiotics covering enteric organisms 1

Thromboprophylaxis

Mechanical prophylaxis (sequential compression devices) should be started immediately as it is safe even with active hematoma. 1, 2, 3

Low molecular weight heparin prophylaxis should be initiated as soon as bleeding is controlled (typically 24-48 hours after hemodynamic stability is confirmed and hemoglobin stabilizes). 1, 2, 3

Follow-up Imaging

Routine follow-up CT is not necessary unless clinical deterioration occurs. 1

Obtain repeat imaging if:

• Abdominal pain worsens or recurs 1
• Fever develops (suggests infection) 1
• Hemoglobin drops unexpectedly 1
• Jaundice or rising bilirubin (suggests biliary complication) 1
• Otherwise, ultrasound at 1-2 weeks is reasonable to assess resolution 1

Common Pitfalls to Avoid

• Do not perform routine percutaneous aspiration or drainage of uncomplicated hematomas as this increases infection risk and may precipitate bleeding 1, 4
• Avoid premature anticoagulation restart; wait 7-15 days after bleeding control before resuming anticoagulation in patients with thromboembolic risk 1
• Do not rush to surgery; most large hematomas resolve with conservative management, and operative intervention carries significant morbidity 1, 4
• Do not overlook coagulopathy correction; inadequate reversal of anticoagulation or failure to maintain adequate fibrinogen/platelets leads to expansion 1

Return to Normal Activity

Normal activity can resume after 3-4 months in uncomplicated cases, or after 1 month if follow-up imaging shows significant healing. 2