Tension Hemothorax - A Dreaded Complication of Percutaneous Liver Biopsy

A 52-year-old man was admitted to our hospital for percutaneous liver biopsy. The indication was to assess his fibrosis stage to determine his treatment for genotype 1b chronic hepatitis C. Informed consent was obtained. Prebiopsy preparation was performed in accordance with recent guidelines.1 The optimal position for needle puncture was marked with ultrasound guidance. The patient was taught to hold his breath in full expiration immediately before biopsy. The liver biopsy was performed with a 16G spring-loaded cutting needle. The first needle pass yielded a small amount of darkish tissue of uncertain nature. A second needle pass was attempted and a core of liver tissue was obtained. The patient developed hypovolemic shock 2 hours after the procedure. He did not complain of any abdominal pain or shortness of breath. Immediate assessment with bedside abdominal ultrasound did not reveal any free intra-abdominal fluid. An urgent computerized tomography scan showed a massive right hemothorax with tension effect. Active contrast extravasation was noted in the right lower lobe of the lung (Figure A). An aggressive blood transfusion was given and a chest drain was inserted to relieve the tension effect. An emergent thoracotomy was performed. Laceration of the medial basal segment of the right lower lobe of the lung was found. Hemostasis was achieved by suturing the parenchymal tear. The patient recovered uneventfully after the surgery. The liver biopsy result was a stage 2 liver fibrosis (METAVIR scale) compatible with chronic hepatitis C. A small piece of normal lung tissue (length, 3 mm) was also included in the liver biopsy specimen (Figure B).

Percutaneous liver biopsy has a small but definite risk of severe complications. The risk of fatal and nonfatal hemorrhages in 9212 percutaneous liver biopsies was 0.11% and 0.24%, respectively.2 Potentially life-threatening complications occasionally can occur above the diaphragm and should not be missed. Preventive measures include meticulous attention to ensure the patient is in full expiration before firing the biopsy needle or the use of real-time ultrasound-guided biopsy. Validation of noninvasive fibrosis markers and FibroScan (Echosens, Paris, France) may obviate the need for this invasive procedure in certain cases.

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