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Liver necrosis: case report A 61-year-old woman developed liver necrosis following trans-arterial embolization with ethiodized-oil. The woman had been diagnosed with metastatic neuroendocrine tumour (NET) following her presentation with a several month history of weight loss, watery diarrhoea, occasional flushes and abdominal pain. She also exhibited bilobar liver metastases. After 2 months, she presented with subacute intestinal obstruction, for which intestinal bypassing of the tumour was required. She started receiving octreotide therapy. She was scheduled to undergo trans-arterial embolization (TAE) of the liver metastases. Subsequently, she underwent TAE via a right femoral approach. The TAE was performed using a total of 10mL of ethiodized-oil [Lipiodol] 480mg iodine/mL [route not stated] and 1 vial of 100–300µm beads. She had no immediate post-procedure complications. One day later, she complained of abdominal pain in the right hypochondrium and nausea. Initially, postembolization syndrome (PES) was suspected; however, her condition deteriorated further over the following days. She experienced worsening lethargy, recurrent vomiting and poor appetite. She had also developed a low-grade fever and signs of fluid overload. Subsequent blood test revealed acute liver injury with disturbed liver profile and an elevated INR (2.3). A CT-scan showed extensive liver necrosis mainly in VII and VIII segments and gall bladder necrosis. Additionally, increased attenuation areas secondary to the ethiodized-oil were noted. A doppler ultrasound revealed thrombosis of the portal vein branches to segments VII and VIII, while other hepatic arteries and veins were patent. Subsequent MRI confirmed a large necrosis in the right hepatic lobe, secondary to thrombosis of the anterior division of the right portal vein [duration of treatment to reaction onset not stated]. The woman started receiving supportive medical therapy. Her condition complicated by fluid overload and sepsis. Blood cultures returned positive for various Bacteroides species, as well as Enterococcus faecium. She started receiving unspecified antibacterial regimen. Subsequently, she had a significant recovery despite liver injury and sepsis. Her liver function improved. After 7 weeks of hospitalisation, she was discharged with antibacterials. After several weeks of discharge, a repeat MRI showed a decrease in size in the necrotic collection with choledocholithiasis and compensatory hypertrophy of the remaining liver segments. The treated liver metastasis showed high-grade necrosis. The pathologically enlarged mesenteric conglomerate of lymph nodes remained overall unchanged. Micallef S, et al. Hepatic necrosis after trans-arterial embolization of metastatic neuroendocrine tumour. European Journal of Case Reports in Internal Medicine 7: No. 5, 19 803503639 Mar 2020. Available from: URL: http://doi.org/10.12890/2020_001530

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Reactions 26 Sep 2020 No. 1823