Because sometimes, the liver heals, but not without leaving a few traps behind.
The Quiet Trouble After the Storm
The bleeding stops, the packs are out, and the ICU is calm. The ventilator’s rhythm is steady; the numbers look kind. You think you’re through it, the liver’s holding, the bile’s drying, the vitals are boring in the best possible way.
And then, weeks later, the phone rings.
The patient’s back. Tachycardic. Pale. Maybe jaundiced. Maybe just “not right.”
CT lights up like a bad memory, a shimmering sac of contrast where no sac should be, or a tangle of vessels with flow that looks far too organized for chaos.
A pseudoaneurysm. Or worse, an arterio-venous fistula.
The liver, once again, has rewritten the rules.
How It Starts
These are not the loud, dramatic bleeds of day one.
They’re the slow-burn complications of a liver that’s tried to patch itself but got the plumbing wrong.
A pseudoaneurysm is the scar that beats.
A weak spot on an artery wall that never fully healed, quietly expanding until it doesn’t.
An AV fistula? That’s the body’s misfire, an artery and a vein joined in secret, trading blood through a handshake that shouldn’t exist.
They don’t announce themselves politely. Sometimes it’s haemobilia, blood creeping into the bile ducts, making the patient vomit crimson or pass tarry stools.
Sometimes it’s just an unexplained drop in haemoglobin, or right upper quadrant discomfort that feels more ominous than tender.
Diagnosis: The Hunt for the Hidden Pulse
CT angiography is your best friend here, a roadmap for where the liver’s gone rogue.
If you see that flash of contrast where there shouldn’t be one, you know you’re dealing with a pseudoaneurysm.
If the arterial phase and venous phase start blurring together, that’s your AV fistula whispering its presence.
Sometimes you’ll see both, the post-trauma duet nobody asked for.
The temptation, especially if the patient looks stable, is to watch and wait. Don’t.
These are time bombs. Small, quiet, and merciless when ignored.
The Modern Fix: Wires, Coils, and Catheters
Gone are the days of reopening and dissecting through a minefield of scar and adhesions.
Endovascular therapy has changed the game.
You call interventional radiology, the quiet magicians with steady hands and cold coffee.
They navigate catheters into vessels you can barely name, and with a twist of wire and a coil or two, they seal the leak, silence the fistula, stop the bleed.
It’s elegant. Bloodless. Almost too easy.
And you walk out of that angiography suite feeling like you got away with something.
But not every centre has that luxury.
When you’re in the middle of nowhere, with a CT that barely loads and no IR team to call, you might have to go old school, control inflow, isolate the segment, resect if you must. It’s crude, but sometimes survival isn’t elegant.
What Not to Forget
Even after the coil’s in, your job isn’t done.
These patients need follow-up, not faith.
Repeat imaging, liver function checks, and a close eye on new fevers or pain. Because post-embolization syndrome is real, fever, transaminitis, and right upper quadrant ache that mimics relapse.
And remember, an embolized liver segment doesn’t just go quiet; it dies. Watch for abscesses, watch for sepsis, and for God’s sake, don’t celebrate too early.
Lessons the Liver Keeps Teaching
If trauma surgery has a patron saint of humility, it’s the liver.
You can patch it, drain it, stent it, and still, it will find new ways to remind you who’s boss.
AV fistulas and pseudoaneurysms are that reminder in slow motion: the body’s way of saying, “I’m still bleeding, just more politely.”
You don’t win against the liver; you negotiate.
And From the Other Side of the Drapes
And while we chase contrast leaks and trace arterial phases, they’re sitting in a ward bed, watching the bruises fade, thinking it’s all behind them.
Then one night, it starts again, the taste of blood, the ache beneath the ribs, the quiet terror that maybe it’s not over.
They don’t care about coils or catheters or pseudoaneurysms.
They just want to go home and not be scared every time their heart beats too hard.
So when you fix the vessel and silence the bleed, remember: to you, it’s closure, to them, it’s getting their life back, one steady heartbeat at a time.
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