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| CASE REPORT |
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| Year : 2019 | Volume
: 11
| Issue : 2 | Page : 106-109 |
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“LIVER CLOT” after periodontal plastic surgery
Manu Bhaskaran Nair, Pratibha Shashikumar
Department of Periodontology, JSS Dental College and Hospital, JSSAHER, Mysore, Karnataka, India
| Date of Submission | 23-Aug-2019 |
| Date of Decision | 02-Oct-2019 |
| Date of Acceptance | 10-Oct-2019 |
| Date of Web Publication | 23-Dec-2019 |
Correspondence Address:
Dr. Manu Bhaskaran Nair
Room No-9, JSS Dental College and Hospital, JSSAHER, Mysuru-15, Karnaraka
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/jicdro.jicdro_23_19
 Abstract | | |
Periodontal surgical procedures could present challenges to the body's clotting mechanism. One such challenge is the uncontrolled hemorrhage that can lead to a life-threatening complication. This case report describes the case of a 20-year-old systemically healthy male patient who reported with an unusual condition of the formation of a “liver clot,” also known as “currant jelly clot,” after 6 days following a semilunar coronally repositioned flap for root coverage. The clot was removed, and the area was irrigated. The patient was recalled after 1 week, wherein the healing was uneventful with no other complication. Uncontrolled bleeding can delay wound healing and activate infection. The liver clot formed, was part of the secondary hemorrhage following 24 h, which interfered with the organization of the physiologic blood clot. Patients should be instructed to undergo blood investigations prior to surgical procedures and should be informed about the possible postsurgical complications that may occur.
Keywords: Currant jelly clot, hemorrhage, hemostasis, liver clot, periodontal plastic surgery
How to cite this article:
Nair MB, Shashikumar P. “LIVER CLOT” after periodontal plastic surgery. J Int Clin Dent Res Organ 2019;11:106-9 |
| Introduction | |  |
Periodontal plastic surgical procedures are performed to correct or eliminate developmental, anatomic, traumatic, or disease-induced defects of the gingiva or alveolar mucosa. Hemorrhage is a common sequel after periodontal surgery that lasts for a short period of time. It can range from a minor leakage at the site of any traumatic injury or surgical procedure to extensive bleeding, leading to a life-threatening complication.[1] Significant postoperative bleeding is not very common as it is generally self-limiting due to the primary closure of the soft tissues following periodontal surgical procedures.[2] Prolonged bleeding is usually associated with oral surgical procedures, particularly tooth extractions, which results in an “open wound.”[1]
The most common challenges faced by the dentist following any surgical procedure include those related to bleeding, infection, and delayed wound healing. At times, patients tend to move their tongue toward the surgical area which results in the dislodgement of the blood clot formed after surgery, resulting in secondary bleeding.
Reports of liver clot formation after dental surgical procedures are limited. This case report depicts a unique and uncommon case of the formation of a “liver clot,” also known as “currant jelly clot,” after 6 days following a semilunar coronally repositioned flap for root coverage.
| Case Report | | |
A 20-year-old male patient was referred to the Department of Periodontology, JSS Dental College and Hospital, Mysore, Karnataka, India, for the evaluation of recession on the maxillary right first premolar. Clinical examination revealed Miller class I recession with an accessory frenal pull with respect to the tooth [Figure 1]. There was no significant medical history. A semilunar coronally repositioned flap was planned after Phase I therapy to cover the recession. | Figure 1: preoperative photograph – Millers Class I recession with an accessory frenal pull
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The patient underwent a routine blood investigation prior to the surgery, and the values were found to be within the normal limits. A semilunar coronally repositioned flap technique was performed as described by Tarnow[3] [Figure 2] and [Figure 3]. The surgical area was then covered with periodontal pack, and no sutures were given. Postoperative instructions were given, and the patient was recalled after 1 week for follow-up.
Postoperative sequela
Six days after the surgical procedure, the patient telephoned and reported back to the department with the complaint of “thick bloody tissue” on the operated site. On examination, a dark red, jelly-like mass was noted on the maxillary right posterior region associated with the surgical site, and remnants of periodontal pack were embedded within the mass [Figure 4]. | Figure 4: formation of liver clot at the surgical site 6 days postoperatively
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The mass was removed with a tissue forceps [Figure 5]. Slight bleeding was noted after the removal of the clot. The area was irrigated with povidone-iodine, and a pressure pack was applied with moist gauze. No further hemorrhage was noted. The obtained mass was given a diagnosis of “liver clot” or “currant jelly clot” based on the clinical appearance similar to the tissue of the liver. The patient was recalled after 1 week, wherein the healing was uneventful, and at 3rd week which showed complete root coverage [Figure 6]. | Figure 6: postoperatve photograph after 3 weeks, wherein healing is uneventful
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| Discussion | | |
Hemorrhage is defined as the escape of blood from the vessels.[2] It can be classified into primary, intermediate, and secondary hemorrhage depending on its occurrence. During surgery, blood vessels get ruptured that results in primary hemorrhage. Intermediate hemorrhage occurs within 24 h after surgery when pressure pack is removed or due to vasoconstrictive agent dissipation. Any infection, foreign bodies, intrinsic trauma, bone replacement graft, or restorative dressing material can cause secondary hemorrhage after 24 h which interferes with the organization of blood clot.[4],[5]
Hemorrhage is followed by the event termed as hemostasis. The two main components of hemostasis include the primary hemostasis (platelet aggregation and platelet plug formation) and the secondary hemostasis (deposition of insoluble fibrin by the proteolytic coagulation cascade). Hemostasis gets activated within seconds of an injury and remains localized to the injured site.
Blood coagulation and fibrinolysis form an important part of the host defense mechanism.[6] Following an injury to the vessel wall, the blood vessels constrict. Platelets are activated and get adhered to the damaged subendothelial tissue at the injured site. This results in the formation of a temporary hemostatic plug. Plasma coagulation factors get stimulated by the platelets, leading to the generation of insoluble fibrin. This forms a mesh incorporated in and around the platelet plug, and the mesh serves to strengthen and stabilize the blood clot. Both components of hemostasis (primary and secondary) happen simultaneously and are mechanistically intertwined. The fibrinolysis pathway plays an important role in hemostasis which dissolves the blood clot once the integrity of the blood vessel has been restored.[2],[6],[7]
“Liver clots” or “currant jelly clots” are defined as a red, jelly-like clot that is rich in hemoglobin from erythrocytes within the clot and characterized by slow, oozing, dark (venous) blood.[8],[9],[10] It can also form due to venous hemorrhage that may not have a pulsating quality.[2] It represents incomplete fibrin clotting and has shown to be associated following the extraction of mandibular third molars.[1] A biopsy of the liver clot confirmed the presence of fibrous band surrounded by erythrocytes.[5]
High-speed suctions or curettes can be used to remove liver clots. Sutures are not generally required.[1] Laser therapy can also be utilized in removing the blood clot and in enhancing the healing of the tissues by biostimulation.[7] Although the occurrence of a liver clot is rare, dental professionals should be skilled enough to prevent and manage such an event.
According to literature, “liver clot formation” occurs after 24–48 h.[7] However, this case describes the formation of a liver clot that has occurred after 6 days.
This case is believed to be the second report of a “liver clot” formed after periodontal plastic surgical procedure utilizing a semilunar coronally repositioned flap for root coverage.
| Conclusion | | |
Prolonged and uncontrolled hemorrhage is always a matter of concern for both dental professionals and patients as it can delay wound healing and activate infection. Primary closure of any surgical wound should be confirmed with a maximum number of sutures necessary for the close adaptation of the wound margins.[2] Pressure packs for about 5–10 min; ice packs; vasoconstrictive substances such as epinephrine; procoagulants (BotroClot, thrombin, and collagen); diode lasers, and electrosurgery are various techniques used to achieve coagulation.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to b'e reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
| 1. | Druckman RF, Fowler EB, Breault LG. Post-surgical hemorrhage: Formation of a “liver clot” secondary to periodontal plastic surgery. J Contemp Dent Pract 2001;2:62-71.  |
| 2. | Bakutra G, Vishnoi S, Chandran S, Barot V. Liver Clot: A reactionary haemorrhage-Case report. Natl J Integr Res Med 2015;6:116-8. |
| 3. | Tarnow DP. Semilunar coronally repositioned flap. J Clin Periodontol 1986;13:182-5. |
| 4. | Lapeyrolerie F. Management of dentoalveolar hemorrhage. Dent Clin North Am 1973;17:523-32. |
| 5. | Jayakrishnan R, Alim A, Basim Burhan KB. Liver clot after flap surgery: A case report. Int Dent J Student's Res 2018;6:35-7. |
| 6. | Riddel JP Jr. Aouizerat BE, Miaskowski C, Lillicrap DP. Theories of blood coagulation. J Pediatr Oncol Nurs 2007;24:123-31. |
| 7. | Natalia E, Irene B. Comprehensive Approach in “Liver Clot” Management Case Report. Biomed J Sci Tech Res 2018; 3:3613-6. |
| 8. | Anderson, KN, Anderson LE. Mosby's Pocket Dictionary of Medicine, Nursing and Allied Health. St. Louis: Mosby Inc.; 1998. p. 311. |
| 9. | Moghadam HG, Caminiti MF. Life-threatening hemorrhage after extraction of third molars: Case report and management protocol. J Can Dent Assoc 2002;68:670-4. |
| 10. | Dinkova A, Kirova D, Delev D. Dental management and bleeding complications of patients on Long-Termoral antiplatelet therapy. Review of existing studies and guidelines. J IMAB 2013;19:298-304. |
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]
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