P1394 - Spontaneous Rupture of Pectoralis Muscle Causing Liver Failure

Rodney A. George-Rivera, MD, Jaymilitte Bosques-Lorenzo, MD, Jose Martin-Ortiz, MD, FACG, Antonio Miranda-Enchautegui, MD
VA Caribbean Healthcare System, San Juan, Puerto Rico

Introduction: Acute-on-chronic liver failure (ACLF) is a process where an inflammatory event leads to decompensation of cirrhosis and extrahepatic organ failure. Approximately 60% of the events leading to ACLF are identified by physicians; alcoholic hepatitis and sepsis account for most of the cases. However, unusual events may lead to ACLF; spontaneous rupture of a pectoralis muscle was the culprit of the following case.

Case Description/Methods: Case of a 61-year-old Hispanic man who presented to the ED due to a right-sided chest and arm pain that woke him up from sleep. Past medical history included cirrhosis secondary to cryptogenic steatotic liver disease and polymyositis. Daily medications included azathioprine 50 mg, prednisone 5 mg, and vitamin E 1000 units. At the ED, the physical exam showed a right-sided hematoma involving the chest and entire upper extremity. Acknowledging that polymyositis is an autoimmune condition against muscles, predisposing them to rupture and bleed, the emergency physician ordered bloodwork and imaging. Results included anemia (Hgb 7.1 g/dL.), right-sided pectoralis/subscapularis muscle rupture, and an 11 cm hematoma. The patient was admitted to the medical ward, where he developed acute moderate ascites and grade 1 encephalopathy. At the time, he had a Child-Pugh class C and MELD score of 23 due to hyperbilirubinemia (5.93 mg/dL), hypoalbuminemia (2 g/dL), a high INR (2.21), low creatinine levels (0.27 mg/dL), and normal sodium levels (136 mEq/L); also seen where mild elevations of AST and ALT (116 U/L and 60 U/L, respectively.) Despite aggressive management, the patient’s hematoma recurred, leading to the suspicion and eventual diagnosis of disseminated intravascular coagulation (DIC.) He decided to receive comfort care only; later, he was admitted to hospice.

Discussion: In our patient, ACLF was evidenced by the sudden onset of ascites, encephalopathy, and DIC following the spontaneous rupture of his pectoralis muscle. Muscle rupture leads to ACLF via liver ischemia, hepatocyte necrosis, and an inflammatory process mediated by damage-associated molecular patterns. Consequently, the 28-day mortality rate of ACLF is 32.8%; thus, identifying unusual triggers is vital when facing the disease.



Disclosures:


Rodney A. George-Rivera, MD, Jaymilitte Bosques-Lorenzo, MD, Jose Martin-Ortiz, MD, FACG, Antonio Miranda-Enchautegui, MD. P1394 - Spontaneous Rupture of Pectoralis Muscle Causing Liver Failure, ACG 2024 Annual Scientific Meeting Abstracts. Philadelphia, PA: American College of Gastroenterology.