Subcapsular Hepatic Hematoma Post- ERCP: Case Report and Review of the Literature
C. Sommariva, A. Lauro, N. Pagano, S. Vaccari, V. D’Andrea, I. R. Marino, M. Cervellera & V. Tonini
Hepatic hematoma is a rare but possible complication of ERCP. We describe the case of a 75-year old man with a large, 8 × 12 cm, sub-capsular and intra-parenchymal hematoma post ERCP, affecting the right liver segments and treated conservatively.
A review of literature has been performed, highlighting two possible mechanisms: hematoma may occur as the result of accidental laceration of a small intrahepatic vessel by the guidewire, whereas the other hypothesis posits that the hepatic damage is secondary to traction on the biliary system exerted by the balloon. We speculate that in case of anomalies of the biliary tree, the incidence of this complication is higher than expected.
In case of hepatic hematoma post ERCP, a conservative approach should always be considered before proceeding to interventional radiologic procedures or to surgical therapy.
Case Report and Evolution
A 75-year-old man was admitted on to the Emergency Department of St. Orsola University Hospital-Bologna due to stabbing, continuous, and worsening epigastric and thoracic pain. During clinical evaluation, he had an episode of vomiting. Vital signs were unremarkable. Relevant past medical history included acute myocardial infarction treated with angioplasty and stents, followed by pacemaker implant for Luciani–Wenckebach second-degree atrioventricular block. He took daily low-dose aspirin. Admission EKG, chest and abdominal X-rays did not reveal significant pathology. Physical examination was remarkable for upper abdominal pain with no rebound tenderness or other signs of peritonitis. Blood tests included Hgb 15.2 g/dL, amylase 1661 U/L, AST 166 U/L, ALT 106 U/L, and total bilirubin 1.8 mg/dL. The patient was admitted to the Internal Medicine Department with the diagnosis of acute pancreatitis. The initial treatment was conservative with fasting without nasogastric tube insertion and therapy with intravenous piperacillin/tazobactam due to low-grade fever. An abdominal CT scan showed evidence of pancreatic inflammation and suspicion of partial biliary obstruction due to choledocholithiasis involving the common bile duct with mild ductular dilation (10 mm) and cholelithiasis. Aspirin therapy was immediately discontinued; 3 days later, ERCP was performed during which the biliary duct was cannulated with a 0.35 inch hydrophilic guidewire (NaviPro™-Boston Scientific) with a sphincterotome (Ultratome™XL-Boston Scientific). Cholangiography revealed a slightly dilated common bile duct with pre-papillary and medium-proximal filling defects. A sphincterotomy was performed with endocut current type using an Erbe™ generator. Eventually, an extraction Fogarty balloon (Extractor™Pro XL-Boston Scientific) was inserted through the guidewire to extract the stones. No residual stones were observed at control cholangiography and a good outflow of contrast dye through the duodenum was documented at the end of the procedure. The immediate post-procedural course was uneventful; the patient left the endoscopic suite asymptomatic with stable vital signs. The ERCP findings and the related cholangiogram are depicted in Figs. 1 and 2.
In the following 2 days, the patient reported the discharge of semifluid dark feces without abdominal pain. Digital rectal examination was negative; since a CBC showed acute severe anemia (Hgb 8.3 g/dL), 1 unit of blood was transfused even though the patient was hemodynamically stable. In order to exclude hemobilia, an EGD was performed, with no signs of active or recent bleeding in the foregut. A repeat abdominal CT scan showed a large 12 × 8 cm subcapsular and intraparenchymal hematoma affecting the right liver segments (VI/VII/VIII) without active bleeding. Pneumobilia was reported, particularly in the left lobe (Fig. 3).
The patient was transferred to the Emergency Surgery Unit, where he was treated conservatively due to clinical stability (subsequent Hgb 8.3 g/dL without additional blood transfusions). In the following days, his clinical condition improved accompanied with increasing Hgb (10.4 g/dL). Abdominal ultrasound with SonoVue™ contrast documented a stable hematoma. The patient was discharged in good clinical condition after 7 days of antibiotic therapy. A CT scan performed after 1 week from discharge showed a stable hematoma.