The way to a man's heart is through his liver

A 57-year-old man with Hepatitis B and C was scheduled for an outpatient computed tomography (CT)-guided biopsy of the left lobe of the liver for grading and staging of his liver disease at an outside hospital. Complete metabolic profile (CMP), complete blood count (CBC) and international normalized ratio (INR) were performed and were normal. Following his liver biopsy, the patient became hypotensive and developed shock. He received fluid resuscitation. Clinical exam and an abdominal x-ray failed to identify a hepatic or intraperitoneal source of bleeding to explain the cause of hypotension. A chest radiograph showed an enlarged cardiac silhouette with clear lung fields. An electrocardiogram (ECG) demonstrated (Figure 1) 1-mm ST segment elevation in the anterior leads. An emergent echocardiogram showed a significant pericardial effusion with echocardiographic evidence of cardiac tamponade. The patient underwent emergent pericardiocentesis with removal of 400 mL of hemorrhagic fluid. The etiology of the hemorrhagic fluid was thought to be due to myocardial injury secondary to the liver biopsy. Subsequently, the histopathology of the liver biopsy reported (Figure 2) features suggestive of cirrhosis of the liver. Additional tissues from the biopsy included pericardium, myocardium and coronary artery. The patient was transferred to our institution for a cardiac catheterization and coronary angiogram to evaluate his coronary anatomy. The coronary angiogram was normal without any evidence of dye extravasation. A follow-up echocardiogram and CT scan of the chest showed residual pericardial and pleural fluid. The remainder of the hospital stay was uneventful and he was discharged on day 7 in good condition. He was doing well a month later at the time of his follow-up visit.