LIVER BIOPSY AND SPLENOPORTOGRAPHY IN PATIENTS WITH THROMBOCYTOPENIA

Transcription

1 GASTROENTEROLOGY Copyright 1968 by The Williams & Wilkins Co. Vol. 54, No. 2 Printed in U.S.A. LIVER BIOPSY AND SPLENOPORTOGRAPHY IN PATIENTS WITH THROMBOCYTOPENIA M. S. LOSOWSKY, M.D., M.R.O.P., AND B. E. WALKER, M.B., OH.B., M.R.O.P. Department of Medicine, University of Leeds, Leeds, England Needle biopsy of the liver and splenoportography are now well recognized procedures which have been increasingly used ill recent years in the investigation of patients with liver disease or splenomegaly. Both procedures are, however, potentially dangerous, and precautions should be taken before they are performed. One of the main dangers of splenoportography or liver biopsy is persistent bleeding from the puncture site. To minimize this danger, leading authorities are agreed that the prothrombin time should not be unduly prolonged, and also that these investigations should not be undertaken in patients with thrombocytopenia. Thus, in relation to liver biopsy, Sherlock! states categorically, "The platelet count should exceed 100,000," and a similar statement is made in reference to splenoportography, while Naish and Read!! state in relation to liver biopsy "There should be no thrombocytopaenia." Cohn,3 in the standard textbook of gastroenterology edited by Bockus, states "A platelet count below 100,000 per cubic millimeter... is reason to withold the procedure" in regard to splenoportography, and, when considering liver biopsy, "The following conditions are considered to contraindicate percutaneous needle biopsy of the liver... a blood dyscrasia that may prcdispose toward bleeding." Rousselot ami Burcheli,4 in Schiff's Diseases of the Liver, state "Contraindications to splenic portography include... a platelet count below 100,000/ cu. mm." Clearly, it would be prudent to abide by this advice wherlever possible, although little Received July 21, Accepted September 19, Address rf.-'quests for reprints to: Dr. M. S. Losowsky, Department of Medicine, The General Infirmary, Leeds 1, England. direct evidence is available in its support. However, when there are strong indications for liver biopsy or splenoportography, and further management of the patient depends on the result of these procedures, it may occasionally be felt necessary to proceed despite laboratory evidence suggesting an increased risk of hemorrhage. In recent years we have felt it desirable to undertake liver biopsy or splenoportography, or both, in a number of patients with platelet counts below 100,000 per mm. 3 No complications have been encountered, and there has been no indication of intraperitoneal hemorrhage. This paper describes 18 consecutive patients in whom liver biopsy, splenoportography, or multiple procedures were carried out, without complications, in the presence of thrombocytopenia. 241 Patients Studied and Methods The patients and their platelet counts, prothrombin times, and diagnoses are shown in table 1. Platelet counts were estimated by the Coulter model A counter on venous blood, collected in ethylenediaminetetraacetate, within 2 hr of being collected, the lower limit of normal being taken as 150,000 per mms. Jaundiced patients and patients with an increased prothrombin time were given parenteral vitamin K for at least 2 days prior to the procedure. Illustrative Case Reports Case I. A 70-year-old woman presented with lassitude and was found to have hepatosplenomegaly and esophageal varices. A presumptive diagnosis of cirrhosis of the liver was made, but liver biopsy was not performed because the platelet count was persistently below 100,000 per mm". She was readmitted with severe and persistent hematemesis 16 months later. Splenoportography was performed when the platelet count was 20,000 per mm s and there were no ensuing signs of intra-

2 TABI,I' Paticnt no.1 Age Sex I'roc.:edurc PIa tckt coun t fi I ----, (; (; (; pl e lloport.ogmm L iver biopsy (1) (2) L iver biopsy (1) (2) (per 111m3) 20,000 88,000 80,000 2(;,000 26,000 50,000 90,000 60,000 58,000 89,000 (;4, , ,000 (same day); 90,000 (5 days later) 61, ,000 88,000 84,000 75,000 66,000 74,000 ProthromLin time ("alien tl control) 15/ 13 13/11 13/11 1()/12 1(;/ 12 lu/12 lu/13 17/ 13 15/12 13/12 lu/14 13/ 13 13/13 13/13 14/13 14/ 12 Recent abnormal blceding Remarks.Easy brui i ll g, h (' lilale ll1eis 31 Nee case reporl days previous Purpura and ecchymoses on See case report admission- cleared wit.h vitamin C before needling History of purpura for 2 See case report years. E asy bruising, bruising after fall. Melena, 3 weeks Nil Hematemesis 3 weeks, purpura on chest and legs Epistaxis, hemoptysis Epistaxis-severe and recurrent Nil Hemoptysis Hematemesis 3 weeks later Hematemesis and melena Liver histology normal. irst spleno por togram unsatisfactory, repea showed ext.rahepatic portal vein ob struction Chronic hepatitis Presented with hematemesis and found to have splenomegaly. Liver histology normal Biopsy showed hemochromatosis Granulomatous hepat it is. No underlying cause found Normal liver hist.ology. Splenic pressure measured. Venous system not. clearly otlt.lined because contrast medium tracked back along t he needle into the peritoneal cavity Biopsy showed port.al cirrhosis Biopsy showed hemochromatosis Biopsy showed normal histology. Dilated splenic vein and esophageal varices shown at first splenoportogram but portal v ein not well filled. Second splenoportogram showed portal v ein obstruction at porta hepatis t-:) >I- 1-':> t.-< >.:: t.-<

3 TABLE I-Continued M 51,000 13/13 Hema temesis and melena 66,000 15/ ,000 14/12 Easy bruising M 85,000 14/13 Nil M 75,000 14/13 Hematemesis and hemoptysis ,000 20/13 Nil ,000 12/11 Generalized purpura and bruising. Submucosal hemorrhage in mouth. Retinal hemorrhage Probable cirrhosis. Insufficient tissue obtained for diagnosis. Intrasplenic pressure grossly raised, splenoportogram showed marked collateral circulation Biopsy showed cirrhosis. showed collateral circulation and abnormal intrahepatic pattern Biopsy showed active chronic hepatitis Extrahepatic portal vein obstruction Biopsy showed probable cirrhosis Biopsy showed metastatic adenocarcinoma ";j "".., '".e «: '- too<... >-<:... 8 a '"t1 a 25 >-<:

4 244 LOSOWSKY AND WALKER Vol. 54-, No.2 abdominal hemorrhage. Since gross esophageal varices were shown, a portacaval anastomosis was performed the following day. At laparotomy the puncture wound in the spleen was well sealed and only a few milliliters of bloodstained fluid were present in the peritoneal cavity. Case II. A 59-year-old woman presented with scurvy due to a grossly inadequate diet associated with schizophrenia. After treatment of the scurvy, gross splenomegaly persisted. A liver biopsy was performed when the platelet count was 88,000 per mm" and showed normal histology. A splenoportogram was performed when the platelet count was 80,000 per mm", and showed a gross abnormality of the portal venous system which was thought to be of congenital origin. There were no clinical signs to suggest intraabdominal hemorrhage after either procedure. Case III. A 29-year-old female had an X-ray of the pelvis following a fall from a motorcycle and the lower margin of the spleen was noted below the pelvic brim. Physical examination confirmed enormous splenomegaly and she then gave a history of purpura for some 2 years. The platelet count was persistently below 30,000 per mm" and usually below 20,000 per mm 3 In an attempt to raise the platelet count temporarily, to enable liver biopsy to be performed, she was given 2 pints of fresh blood rapidly but serial estimations of the platelet count following transfusion showed no rise at all. It was felt important to obtain a diagnosis and so, some days later, liver biopsy and splenoportography were performed together when the platelet count was 26,000 per mm", with fresh blood and facilities for laparotomy available immediately if required. with a Menghini needle was unsuccessful, splenic manometry confirmed portal hypertension, and splenoportography showed a well marked collateral circulation. A second needle biopsy was performed 3 days later using a Vim Silverman needle when the platelet count was 26,000 per mm", and histology showed postnecrotic cirrhosis. An end to side portacaval anastomosis was performed, following which there was a slight reduction in splenic size and a slight rise in the p13telet count but severe thrombocytopenia remained. A further splenoportogram was performed when the platelet count was 50,000 per mm"; it showed marked narrowing at the an[1stomosis, and the splenic pressure was still high. There were no signs of intraabdominal hemorrhage after any of the needling procedures. Splenectomy was then performed and the splenic vein anastomosed to the systemic venous system. The platelet count rapidly rose to well within normal limits and the patient remains well. Discussion Although thrombocytopenia is stated to be a contraindication to liver biopsy or splenoportography there seems little evidence in support of this. With regard to liver biopsy, Zamcheck and Klausenstock 5 reviewed over 20,000 liver biopsies in which there were 39 fatalities, of which 25 were due to massive hemorrhage. In 7 fatal cases the prothrombin time was markedly raised and biopsy might well have been postponed. In none of the fatal cases was there any record of the platelet count and thus thrombocytopenia cannot be incriminated. Whitesell and Snell 6 record four liver biopsies in patients with platelet counts below 100,000 per mm:1 and in none of these was hemorrhage a complication. We have been unable to find any reports of patients dying following liver biopsy in the presence of thrombocytopenia. Significant hemorrhage following splenoportography is estimated to occur in 1 to 2% of cases,7-9 although when laparotomy is performed shortly afterward it is not uncommon to find a few milliliters of blood in the peritoneal cavity.l0-12 O'Sullivan and Evans 13 described 18 patients in whom laparotomy was performed immediately after splenoportography and, although there was blood in the peritoneal cavity of several, there was active bleeding in only one, a patient with severe pancytopenia. Block and J acobson 14 performed splenic punctures in a variety of conditions, using a Vim Silverman needle. Ten of their patients had platelet counts below 100,000 per mm 3 and only one of these bled severely from the puncture wound. This patient had a platelet count of 60,000 per mm 3 and, owing to an error of nursing orders, was mobilized too early after the procedure and subsequently showed signs of intra abdominal hemorrhage which required multiple transfusions; this was followed by oliguria. Another patient with a platelet count of 98,000 per mm 3 showed signs of intracranial hemorrhage 3 hr after

5 ebruary 1988 LIVER BIOPSY AND SPLENOPORTOGRAPHY 245 the procedure. He died 36 hr later and at autopsy there was no evidence of bleeding from the splenic puncture. Thus the risk of hemorrhage following liver biopsy and splenoportography is certainly present but in the former there is no evidence that it is increased in the presence of thrombocytopenia, while in the latter the evidence is, at best, fragmentary. After administration of parenteral vitamin K it is our experience that, in patients in whom the diagnosis is in doubt, the prothrombin time is rarely so abnormal as to constitute a contraindication to liver biopsy or splenoportography. In one patient (no. 17), however, the prothrombin time was 7 sec above the control value and there were no complications. We have found the bleeding and clotting times to be so rarely abnormal in these patients as to be of no value in assessment. Other tests of clotting or platelet functions were not performed. resh blood in patient 3 failed to raise the platelet count, perhaps because of the enormous splenomegaly, but nevertheless concentrated platelet suspensions might be used to attempt to raise the platelet count, especially if the spleen is not grossly enlarged. We have encountered no complications from these procedures in patients with thrombocytopenia despite clinical evidence of hemorrhage from various sites (table 1). We would not, however, suggest that the classical contraindications should be ignored. We feel nevertheless that, if management of the patient demands liver biopsy or splenoportography, then thrombocytopenia or clinical hemorrhage should not be absolute contraindications to these procedures, provided that they are carried out by experienced operators and facilities for transfusion and, if necessary, laparotomy are available. Summary Eighteen patients are described in whom liver biopsy or splenoportography, or both, was performed, without complications, in the presence of thrombocytopenia. With adequate safeguards, we would suggest that the morbidity of liver biopsy or splenoportography in the presence of thrombocytopenia need not be regarded as prohibitive. REERENCES 1. Sherlock, S Diseases of the liver and biliary system, Ed. 3, p. 56 and 177. Blackwell Scientific Publications, Oxford. 2. Naish, J. M., and A. E. A. Read Basic gastroenterology, p Wright, Bristol. 3. Cohn, E. M In H. L. Bockus [ed.], Gastroenterology, Ed. 2, Vol. III, p. 167 and 164. Saunders, London. 4. Rousselot, L. M., and A. R. Burchell Portal venography and manometry, p In L. Schiff [ed.], Diseases of the liver, Ed. 2. J. B. Lippincott, Philadelphia. 5. Zamcheck, N., and O. Klausenstock The risk of needle biopsy. New Eng. J. Med., 249 : Whitesell,. B., and A. M. Snell Thrombopenia and increased capillary fragility in hepatic disease. J. A. M. A. 140: Baron, M. G., and B. S. Wolf Splenoportography, p In H. Popper and. Schaffner [eds.], Progress in liver diseases. Vol. 1, Grune and Stratton, London. 8. Panke, W.., E. G. Bradley, A. H. Moreno,.. Ruzicka, and L. M. Rousselot Technique, hazards, and usefulness of percutaneous splenic portography. J. A. M. A. 189: igley, M. M., W. J. ry, J. E. Orebaugh, and H. M. Pollard Percutaneous splenoportography. Gastroenterology 28: Gvozdanovic, V., and E. Hauptman urther experience with percutaneous lienoportal venography. Acta Radiol. 43: DuBoulay, G. H., and B. Green Portal venography in Banti's disease. Brit. J. Radiol. 27 : Cooper. D. R., R. C. Brown, C. H. Stone, and L. K. erguson Splenoportography. Ann. Surg. 138: O'Sullivan, W. D., and J. A. Evans Splenoportal venography. Surg. Gynec. Obstet. 101: Block, M., and L. O. J acobson Splenic puncture. J. A. M. A.142: