Liver Capsule Rupture Leads to Emergency

Key Takeaways

Extracorporeal shock wave lithotripsy (ESWL) is a widely used, non-invasive nephrolithiasis treatment that is considered safe, with minimal side effects. However, Georg Prange and colleagues from Sankt Katharinen Hospital, Frankfurt am Main, Germany, encountered an unexpected complication in a 44-year-old man, challenging the conventional understanding of ESWL’s safety profile.

The Patient and His History

The patient in good general and nutritional condition presented for stone removal due to nephrolithiasis. His medical history included multiple ESWL and ureteroscopy (URS) procedures. Following a left ureteral injury during URS, the patient underwent robot-assisted end-to-end left ureteral anastomosis.

Pre-ESWL Evaluation

• Non-contrast abdominal CT revealed a solitary cast stone in the upper right calyx, with no other stones on either side.
• Sonography revealed mild renal pelvic dilatation in the right kidney without urinary obstruction, and the left kidney was significantly smaller, with no evidence of outflow obstruction.

Shock Wave Therapy

• Outpatient ESWL was performed on the right kidney, without a ureteral stent, according to the patient’s preference.
• The procedure was performed smoothly, and the patient was subsequently discharged.
• Later the same day, he returned with right flank pain radiating to the genitals, nausea, and vomiting. He was treated with metamizole and Buscopan.
• Ultrasonography showed mild right-sided renal ectasia with no signs of a perirenal haematoma.
• A double J ureteral stent was inserted without any complications.
• The following morning, he complained of abdominal pressure.

Findings and Recovery After ESWL

• Sonography revealed free intraperitoneal fluid.
• The haemoglobin level dropped from 12.6 g/dL to 7.7 g/dL.
• CT of the abdomen and pelvis revealed a large subcapsular and subdiaphragmatic liver haematoma, liver capsule tear, and free intraperitoneal fluid.
• Laparotomy revealed significant intraperitoneal bleeding with fresh clots and a liver capsule tear extending along the entire right lobe of the liver.
• The patient had an uncomplicated recovery and was discharged after a 7-day hospitalisation.

Discussion

According to the authors, liver capsule rupture following right-sided ESWL is an extremely rare complication of this procedure. ESWL is considered the least invasive treatment, with the lowest complication rate, ranging from approximately 3% to 7%.

Minor complications include flank pain, macroscopic haematuria, urinary stasis due to obstructive debris in the renal pelvis or ureter, hypotension, and infections. Serious complications include urosepsis, bleeding, and renal parenchymal injuries.

The incidence of perirenal haematomas in the literature ranges from 0.28% to 4.1%. Injury to the intraperitoneal liver is rare and is usually characterised by a subcapsular haematoma. To date, no cases of the liver capsule with subsequent hemoperitoneum have been reported.

The increasing shift of urological procedures to outpatient settings with declining reimbursement for URS may lead to a renewed increase in ESWL use. Prange and colleagues emphasised the need for urologists to remain vigilant regarding potential ESWL-related complications.

This article was translated from Univadis Germany using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.