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Authors: Dr. Hemang Mangukia, Dr. Ravikiran, Dr. Kratika Baldua

Abstract-

Bleeding is a common sequela of periodontal and oral surgery. Generally, bleeding is self-limiting. Special circumstances require additional procedures to reduce or eliminate active hemorrhage. Occasionally hemorrhage can be under control when a patient is dismissed from their surgical appointment and, subsequently, the patient will experience either slow seepage of blood or extravascular clot formation. This case report describes the unique formation of a "liver clot" or "currant jelly clot" following tooth extraction. Despite the fact that dental extraction is considered to be a minor surgical procedure, some cases may present with life-threatening complications including hemorrhage. Vigilant and significant history taking, physical and dental examinations prior to dental procedures are a must to avoid intraoperative and postoperative complications.

Keywords: Oral surgery, periodontal surgery, hemorrhage, "liver clot," "currant jelly clot"

Introduction

Postoperative problems may also be common or specific to the category of surgery undergone. Common general postoperative complications include postoperative fever, hemorrhage, wound infection, deep vein thrombosis, and embolism.1 The maximum occurrence of postoperative complications is between 1 and 3 days following the operation. On the other hand, precise complications occur in the subsequent distinct temporal patterns: Early postoperative, numerous days after the operation, during the postoperative phase, and in the delayed postoperative period.1

Immediate postoperative complications include primary hemorrhage-starting during surgery or subsequent postoperative amplification in blood pressure, shock-blood loss, acute myocardial infarction, pulmonary embolism or septicemia, and at last, low urine production-insufficient fluid substitute intraoperatively and postoperatively.2 Early postoperative problems include acute confusion-dehydration and sepsis, nausea and vomiting, fever, analgesia or anesthesiarelated, secondary hemorrhage-frequently as a result of infection, and wound dehiscence.1, 2

Late postoperative complications include constant sinus tract formation, reappearance of lesions that are treated by surgery example: Keloid formation, cosmetic appearance, and malignancy depend on numerous factors.3 Oral surgical procedures mainly tooth extraction can be connected with an extended hemorrhage owed to the nature of the practice ensuing in an “open wound.”4The attempt of this case report is to present a case of massive postoperative clot formation after tooth extraction and highlight on the oral complications of surgical procedures.

Case report

A 40-year-old male reported to the Department of Periodontics, Darshan Dental College and Hospital, Udaipur with chief complaints of blackish growth in his upper front tooth region since 2 days. Patient has undergone extraction of permanent right maxillary canine three days back, tooth was grossly carious and patient wasn’t willing to go for root canal treatment. One day after extraction patient developed clot at the extraction site. Patient went to some private clinic for the management of bleeding; private practitioner has given tranexamic acid to the patient to stop the bleeding.

On clinical examination, a dark red, jelly-like pedunculated mass was noted in relation to the right maxillary canine. The mass was removed with a curette. No hemorrhage was evident at the time of removal of clot. The socket flap was reflected again to visualize for any foreign body, but nothing was evident. 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.

Figure 1: A Dark Red, Thick Jelly like Mass on Maxillary right canine (Buccal View) Figure 2 removal of clot with curette
 
Figure 3 Gross pathology
Figure 3 Gross pathology
 
Figure 4 Histopathology 10x Fibrous band surrounding space
filled with RBCs
Figure 4 Histopathology 10x Fibrous band surrounding space filled with RBCs
 
Figure 5 Immediate Post-operative Figure 6: Post-operative after 1 week
 
Figure 7 Extrinsic Pathway Figure 8: Intrinsic Pathway

Discussion: Haemorrhage is defined as an escape of blood from blood vessels (the vascular compartment which contains approximately 5 percent of the total body fluid). Based on the time of occurrence, haemorrhage can be classified as primary, reactionary and secondary. Primary haemorrhage occurs during time of surgery and is attributed to the cutting of the blood vessels. Reactionary haemorrhage 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 haemorrhage occurs after 24 hours of surgery and is frequently attributed to many factors, like; infection, intrinsic trauma, presence of foreign bodies, that may cause repeated, delayed organization of blood coagulum. The result may range from an aggressive oozing haemorrhage of blood that continuously fills the oral cavity, to a liver clot, to mere blood-tinged saliva that causes alarm to the uninformed patient.5,6

“Liver clot” or “currant jelly clot” are defined as a red, jellylike clot that is rich in haemoglobin from erythrocytes within the clot. Another reason for the formation of a liver clot is venous haemorrhage, which may not have a pulsating quality. The flow will be slightly less rapid and there will be a darker red colour. The above mentioned factors hamper blood clotting. The normal clotting mechanism is as described in the Figures 7 and 8.7 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. 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 vasodilatation, possibly mediated by beta- adrenergic receptors.8 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 is a suture required.9

Conclusion:

Prolonged or uncontrolled bleeding is distressing for both patients and clinicians, and can delay completion of the procedure, compromise wound healing and predispose to infection. Primary closure of surgical wounds should be maximized using adequate sutures to insure close adaptation of wound margins. Following the surgical procedure, moist gauze should be placed over the surgical site with moderate pressure for 5 to 10 minutes. If bleeding persists, vasoconstrictive substances such as epinephrine or pro-coagulants such as thrombin or collagen may be employed.10

References:
  • Thompson JS, Baxter BT, Allison JG, Johnson FE, Lee KK, Park WY. Temporal patterns of postoperative complications. Arch Surg 2003; 138:596-602.
  • Association of Anaesthetists of Great Britain and Ireland, Thomas D, Wee M, Clyburn P, Walker I, Brohi K, et al. Blood transfusion and the anaesthetist: Management of massive haemorrhage. Anaesthesia 2010; 65:1153-61.
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  • 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.
  • Alling CC III, Alling RD. Hemorrhage and shock. In:Kruger GO, editor. Textbook of Oral and Maxillofacial Surgery, 6th ed. New Delhi: JaypeePublishers; 1990. p. 229-54.
  • Lapeyrolerie F. Management of dentoalveolar hemorrhage. Dent Clin North Am 1973;17:523-32.
  • Guyton AC, Hall JG. Textbook of medical physiology. 11thed, Delhi: Jaypee Brothers Medical Publishers; Philadelphia: Publication house- Elsevier; 2006. p. 461-2.
  • Fonseca RJ. Anesthesia/ dentoalveolar surgery/ office management.1st ed, Philadelphia: Publication House-Saunders; 2000. p. 67-8.
  • 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.
  • Greenstein G. Practical periodontics: a review of core periodontal treatment principles. DentToday 2008; 27:66,68,70-3.

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