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Hemorrhagic Shock One Month Following Uncomplicated Liver Transplantation

A 46-year-old Caucasian man with Laennec’s cirrhosis underwent orthotopic liver transplant with duct-to-duct reconstruction performed over an 8 French infant feeding tube. His day 1 hepatic Doppler was normal. He enjoyed an uncomplicated postoperative course and was discharged to home on day 7 with normal allograft function. One month following transplantation, he was evaluated in the emergency department for syncope during which he sustained a jaw fracture. The patient complained of a week history of progressive dizziness and weakness as well as diffuse epigastric and periumbilical pain. 
 
Initial vital signs were temperature 97.4 F, pulse rate 108, respirations 20 and blood pressure 108/66. Physical examination revealed abdominal tenderness and an obvious jaw deformity. The following laboratories were obtained (compared with values obtained 2 days prior): white blood cell 26.6 (11.9), hematocrit 29% (34), platelet count 197 (196), serum chemistries were normal, blood-urea-nitrogen/creatinine ratio 40/1.5 (39/1.3), aspartate aminotransferase 147 (19), alanine aminotransferase 94 (29), alkaline phosphatase 266 (212), gammaglutamyltransferase 452 (269) and total bilirubin 2.2 (1.0). CT scan demonstrated a round hyperdensity area at the porta hepatis on the IV contrast images (Figure 1). There also was evidence of contrast material in the small bowel despite the lack of oral contrast administration. Preparations were made for emergent operative exploration. However, he experienced massive hematemesis and expired despite intensive resuscitative efforts. 
 
 
 
Figure 1 
 
CT of the abdomen shows a collection in the porta hepatis/gallbladder fossa that represents a hematoma (labeled H) 
 
 
 
Postmortem examination revealed large amounts of blood in the gastrointestinal tract and also the peritoneal cavity. The arterial and biliary anastomoses were anatomically adjacent to each other. The arterial anastomosis was dilated, paper-thin and disrupted. Probing of the arterial anastomosis revealed a fistulous tract that communicated with the bile duct anastomosis. 
 
Microscopically, acute and chronic inflammation and focal necrosis were demonstrated in the disrupted hepatic artery wall. Abundant fungi (Candida species) were seen in the wall of the hepatic artery. Postmortem blood culture was positive for yeast.