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The New York Presbyterian Hospital Weill-Cornell Medical Center New York, NY 10021
Subcapsular liver lesions include hematomas, bilomas, abscesses, air collections, lymphoceles, metastatic tumors, chronic schistosomiasis japonica, surface veins, and other rare disorders [1, 2]. I present an unusual case of liver capsular injury resulting in subcapsular accumulation of oral contrast material.
An 85-year-old woman presented to our emergency department with abdominal pain. She had a remote history of a Billroth II gastrectomy and right hemicolectomy. Abdominal radiographs showed dilated loops of small bowel with air–fluid levels, a finding that is consistent with a partial small-bowel obstruction. A contrast-enhanced CT scan revealed the transition point of the obstruction in the right lower quadrant. No obstructing mass was identified.
The patient was admitted for observation. Her condition did not improve, and on the third day after her admission, she underwent surgery. A circumferential fibrous adhesion on the serosal surface of the bowel was discovered, and a partial small-bowel resection was performed. One week later, the patient complained of right-sided abdominal tenderness.
A follow-up contrast-enhanced CT scan showed oral contrast material and a few small bubbles of air surrounding the lateral border of the right lobe of the liver in the subcapsular space. Low-density ascites in the subphrenic recess helped to delineate the outline of the subcapsular space. The contrast material could be traced inferiorly from the subcapsular space to the small-bowel anastomotic site in the right upper quadrant of the abdomen (Figs. 2A, 2B, 2C, 2D). These findings are consistent with a postoperative fistula between a disrupted intestinal anastomosis and the subcapsular liver space (Fig. 2D). A percutaneous drain was subsequently placed into the subcapsular collection.
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The liver capsule is composed of two adherent layers: a thick fibrous inner layer called Glisson's capsule and an outer serous layer that is derived from the peritoneum. Glisson's capsule covers the entire surface of the liver and the serous layer covers most of the liver surface, excluding the bare area near the diaphragm, the porta hepatis, and the area where the gallbladder is attached to the liver. Fluid, blood, and other benign and malignant entities may occupy the subcapsular space, deep relative to Glisson's capsule and superficial relative to the liver parenchyma. Hematomas are the most common subcapsular collections. They may result from a blunt or penetrating trauma or may be a complication of pregnancy, surgery, biopsy, or extracorporeal shock wave lithotripsy [3, 4].
The inferior surface of the liver normally abuts the stomach, duodenum, and right colonic flexure. Because our patient had undergone a Billroth II gastrectomy and right hemicolectomy, the stomach, duodenum, and right colon were no longer present. The small bowel probably abutted the inferior surface of the liver, increasing the risk of liver capsule injury during the small-bowel resection.
A postoperative anastomotic leak communicating with the subcapsular liver space is a rare complication of small-bowel surgery that, to my knowledge, has not been previously described in the literature. Contrast-enhanced CT performed with soluble oral contrast medium is an indispensable tool in making a timely diagnosis of this unusual entity.
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  S. Kim, T. U. Kim, J. W. Lee, T. H. Lee, S. H. Lee, T. Y. Jeon, and K. H. Kim The Perihepatic Space: Comprehensive Anatomy and CT Features of Pathologic Conditions RadioGraphics, January 1, 2007; 27(1): 129 - 143. [Abstract] [Full Text] [PDF]
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