“Liver clot”—A rare periodontal postsurgical complication

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Case Report
“Liver clot”—A rare periodontal postsurgical complication
Dhara Pandya, Balaji Manohar, LK Mathur, Rajesh Shankarapillai
Department of Periodontics,
Pacific Dental College
and Hospital, Debari,
Udaipur-313024, Rajasthan,
India
ABSTRACT
Received
: 27-12-2010
Review completed : 01-03-2011
Accepted
: 07-08-2012
Bleeding is a common sequela of oral and periodontal surgery. Generally, bleeding is self-limiting.
Following traumatic injury or surgical procedures, hemorrhage can range from a minor leakage
or oozing at the site, to extensive bleeding leading to complete exsanguinations. Significant
postsurgical hemorrhage following periodontal surgery is uncommon due to the primary closure
of the soft tissues. This case report describes the unique formation of a “liver clot” or “currant
jelly clot” following periodontal flap surgery. The likelihood of this may be attributed to many
factors, like infection, intrinsic trauma, presence of foreign bodies like splinter of bone, a fleck
of enamel, or a piece of dental restorative dressing material that may cause repeated, delayed
organization of blood coagulum.
Key words: “Currant jelly clot”, hemorrhage, “liver clot”, oral surgery, periodontal surgery
Periodontal surgical procedures are a common component of
comprehensive dental and periodontal practice. Significant
postsurgical hemorrhage following periodontal surgery is
uncommon. Though oral surgical procedures, particularly
tooth extraction; can be associated with a prolonged
hemorrhage due to the nature of the procedure resulting
in an “open wound”.[1]
The surgical postoperative complications can be grouped
into the two major categories: those related to bleeding
and those related to infection and delayed wound healing.
The surgical procedure presents a challenge to the body’s
hemostatic mechanism. There are several reasons for this
challenge. First, the tissues of mouth and jaw are highly
vascular. Second, the extraction of a tooth leaves an open
wound and with both soft tissue and the bone open; which
allows additional bleeding during surgery. Third, patients
tend to play with the area of surgery with their tongue
and occasionally dislodge the blood clot, which initiates
secondary bleeding. The tongue may also cause secondary
bleeding by creating small negative pressures that cause
Address for correspondence:
Dr. Dhara Pandya
E-mail: [email protected]
Website:
www.ijdr.in
PMID:
***
DOI:
10.4103/0970-9290.102244
419
CASE REPORT
A 22-year-old girl reported to the Department of
Periodontics, Pacific Dental College and Hospital, Udaipur
for evaluation and treatment of gingival bleeding and
presence of periodontal pocket on the mesial and distal
aspect of tooth #16.
Clinical evaluation of #16 revealed bleeding on probing
and presence of a 7 mm periodontal pocket on mesial and
distal aspects. Radiographic evaluation revealed moderate
amount of bone loss.
Root planing and subgingival curettage were performed at
the initial appointment. Clinical symptoms subsided a few
days later, but, the pockets were still present. Therefore,
a periodontal flap surgery procedure was planed to treat
the site.
Surgical procedure
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suction of the blood clot from the area. Finally, salivary
enzymes may lyse the blood clot before it gets organized
and before the ingrowth of granulation tissue.[2]
Prior to surgical procedure, routine hematological
examinations were done and all the values were found
to be within normal limits. A Kirkland flap design was
performed in the area by giving an intra sulcular incision.
A full thickness flap was raised from the mesial aspect of the
#15 to distal of #17. After debridement, the flap was sutured
using 3-0 silk suture. [Figure 1]
Periodontal pack was not placed. Literature suggests that
periodontal pack may be used as an aid in hemostasis
Indian Journal of Dental Research, 23(3), 2012
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Pandya, et al.
Liver clot
and protect the surgical site, but it can be dislodged by
severe hemorrhage or subperiosteal hematoma formation.
Hemostasis was obtained and postsurgical instructions were
given to the patient. Instructions included a warning not to
manipulate the surgical site or attempt to retract the lip to
visualize the surgical area.[1]
Antibiotic medicament prescribed was capsule
doxycycline 200 mg twice a day for one day followed by
once a day for six days and analgesic ketorolac dispersible
tablet 20 mg twice a for three days.
A 0.2% chlorhexidine gluconate mouth rinse was
recommended to replace the traditional mechanical oral
hygiene procedures until the first postsurgical visit.
Postoperative Sequela
Patient reported to department the very next morning
with a complaint of inability to occlude due to presence
of some foreign material at the surgical site. On clinical
examination, a dark red, jelly-like pedunculated mass was
noted in relation to the surgical site [Figure 2]. The mass
was removed with a curette [Figure 3]. No hemorrhage was
evident at the time of removal of clot. The periodontal flap
was reflected again to visualize for any foreign body, but
nothing was evident [Figure 4]. The site was irrigated with
povidone iodine solution and flap was secured back to its
original position with sutures.
A diagnosis of “liver clot” or “currant jelly clot” was made
based on clinical presentation.
DISCUSSION
Based on the time of occurrence, hemorrhage can be classified
as primary, intermediate or secondary. Primary hemorrhage
occurs during time of surgery and is attributed to the cutting of
the blood vessels. Intermediate hemorrhage refers to bleeding
that occurs within 24 hours of surgery. The likelihood of this
may be attributed to many factors, like; removal of pressure,
dissipation of vasoconstrictive agents and relaxation of blood
vessels. Secondary hemorrhage occurs after 24 hours of surgery
and is frequently attributed to many factors, like; infection,
intrinsic trauma, presence of foreign bodies like splinter of
bone, a fleck of enamel, or a piece of dental restorative dressing
material that may cause repeated, delayed organization of
blood coagulum. The result may range from an aggressive
oozing hemorrhage of blood that continuously fills the oral
cavity, to a liver clot, to mere blood-tinged saliva that causes
alarm to the uninformed patient.[4,5]
Another reason for the formation of a liver clot is venous
hemorrhage, which may not have a pulsating quality. The
flow will be slightly less rapid and there will be a darker
red color.[4] The above mentioned factors hamper blood
clotting. The normal clotting mechanism is as described in
the Figures 5 and 6.[6]
This cascade suggests that the mechanism is such that one
factor will activate the following factor in a sequenced
reaction resulting in formation of clot.
“Liver clot” or “currant jelly clot” are defined as a red, jellylike clot that is rich in hemoglobin from erythrocytes within
the clot. Liver clots are generally removed by either high
speed suction or a large curette. Following removal of the
clot, saline irrigation and direct pressure is applied to the
exposed area. Rarely are sutures required.[1]
Hemorrhage in its simplest definition refers to the escape
of blood from blood vessels (the vascular compartment
which contains approximately 5 percent of the total body
fluid).[4]
CONCLUSION
Figure 1: Flap secured with Sutures
Figure 2: Presence of clot at the surgical site
Indian Journal of Dental Research, 23(3), 2012
When a patient presents with a significant postsurgical
hemorrhagic sequel or positive history for prolonged
420
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Pandya, et al.
Liver clot
Figure 3: Clot removed with the help of curette
Figure 4: Surgical site reopened
Figure 5: Intrinsic pathway
bleeding, laboratory blood studies are helpful in determining
specific risks or contraindications to invasive dental
procedures.[1]
Sometimes, after periodontal surgery there is formation
of what is called a liver clot. It represents incomplete
fibrin clotting and manifests as a slowly developing,
red-brown clot. It is usually due to venous hemorrhage.
The patient may have difficulty controlling the bleeding
with pressure alone. If the patient calls from home, have
them wipe away the clot with a piece of gauze and apply
pressure for 10 minutes. In the office, inject bleeding
sites with 1/50,000 epinephrine, curette the oozing fibrin
421
Figure 6: Extrinsic pathway
clot away and suture the area or if bleeding persists,
vasoconstrictive substances such as thrombin or collagen
(procoagulants) may be employed.[7] The haemostatic
action of vasoconstrictor must be weighed against the
observation that the frequency of postoperative bleeding
is higher and the healing of extraction socket is delayed
when epinephrine is employed. This phenomenon may
involve a rebound vasodilation, possibly mediated by
beta- adrenergic receptors. [8] Another technique for
coagulation is the use of diode lasers and electro surgery.
Diode lasers are very effective for soft tissue applications
Indian Journal of Dental Research, 23(3), 2012
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Pandya, et al.
Liver clot
including incision, hemostasis and coagulation. Many
advantages of the laser vs. the scalpel blade have been
discussed in the literature. These include a blood less
operating field, minimal swelling and scarring and
much less or no postsurgical pain. When laser surgical
procedures are carried out, the wound heals favorably,
without the need for sutures or surgical dressings.
Electrocoagulation is the biterminal technique utilizing
the partially rectified or fully modified rectified
concentrated current to coagulate the organic content of
the tissue without penetrating deeply the adjacent tissue.
Kenneth et al investigated histologically the reaction of
alveolar bone after gingival incision by electrosurgery
using undamped fully rectified current and found that
at 12 hours post operatively there is more soft tissue
necrosis, more extensive inflammatory reaction, and
greater destruction of the periosteum after electrosurgery.
Necrosis of bone is also seen extensively at 48 hours.[9]
Laser surgery introduced a promising technology that
would combine the rapid healing of the scalpel surgery
and the minimal bleeding of electrosurgery. Therefore
lasers are a tremendous asset in soft tissue surgeries
like gingivectomy/gingivoplasty, flap surgeries, gingival
sculpting associated with periodontal plastic surgical
procedures because of their proven haemostatic action.
Indian Journal of Dental Research, 23(3), 2012
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How to cite this article: Pandya D, Manohar B, Mathur LK, Shankarapillai
R. "Liver clot"-A rare periodontal postsurgical complication. Indian J Dent
Res 2012;23:419-22.
Source of Support: Nil, Conflict of Interest: None declared.
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