Subcapsular hepatic hematoma following ERCP: case report and review

 

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A 76-year-old woman, who was receiving anticoagulation for atrial fibrillation, was referred to our center for management of a common bile duct stone diagnosed by endoscopic ultrasonography. Anticoagulation was suspended and endoscopic retrograde cholangiopancreatography (ERCP) was subsequently performed. Cannulation of the main bile duct with a 0.035-inch guide wire was achieved without complications. Endoscopic biliary sphincterotomy was performed and stone extraction with a Fogarty catheter was achieved successfully, without apparent complications. Subsequently, the patient developed sharp right upper quadrant pain 6 hours after the procedure, but showed no signs of hemodynamic instability, and laboratory data did not show any evidence of complications. By 24-hours after the procedure, she was asymptomatic and was discharged after the reintroduction of anticoagulation.

The patient consulted again 5 days later because of persistent pain. Abdominal examination elicited mild right upper quadrant pain without tenderness. Laboratory data showed hemoglobin 9.6 g/dL (normal range 12 – 15 g/dL) and hematocrit 30.7 % (normal range 36 – 41 %). Computed tomography showed two high-density collections consistent with hematomas within the subdiaphragmatic and subhepatic spaces ([Fig. 1]). The patient was managed conservatively. Anticoagulation was discontinued and a broad-spectrum antibiotic (piperacillin–tazobactam) was administered. The patient was discharged 15 days after the ERCP, without any further complications.

Fig. 1 Computed tomography showing subdiaphragmatic and subhepatic hematomas.

Subcapsular hepatic hematoma is a rare complication of ERCP. There are few published reports of this unusual complication [1] [2] [3] [4] [5] [6] [7] [8] [9] [10], which may be explained by accidental puncture of the intrahepatic biliary tree by the guide wire. In this case, the patient probably developed an initial hematoma 6 hours after the procedure, which worsened because of the resumption of anticoagulation.

From the literature [1] [2] [3] [4] [5] [6] [7] [8] [9] [10] ([Table 1]), there is unanimous concern about the risk of infection in these patients, and in all cases, except two where no detail was given, patients were treated with antibiotics. Most of the patients including our own (6/11) were observed; three were treated by percutaneous drainage; and one each by embolization and surgery. There were no long term complications.

Table 1 Patient characteristics from the reports of hematoma post endoscopic retrograde cholangiopancreatography (ERCP). Age/ Sex Indication for ERCP Guide wire Puncture Treatment Antibiotic Ortega et al. 2000 1 81/M Common bile duct stone NA Yes, positive culture Percutaneous drainage Yes Horn et al. 2004 2 88/F Pancreatic cyst Yes No Observation Yes Chi et al. 2004 3 43/F Pancreatic cancer Yes No Embolization Yes Priego et al. 2007 4 30/F Obstructive jaundice NA No Surgery, positive culture Yes Petit-Laurent et al. 2007 5 98/M Common bile duct stone Yes Yes, negative culture Percutaneous drainage NA Bhati et al. 2007 6 51/F Common bile duct stone Yes Yes, negative culture Percutaneous drainage NA McArthur et al. 2008 7 71/M Common bile duct stone Yes No Observation Yes De la Serna et al. 2008 8 71/F Common bile duct stone Yes Yes, negative culture Observation Yes Cárdenas et al. 2008 9 54/M Bile leak post liver transplant Yes No Observation Yes Revuelto et al. 2010 10 41/M Common bile duct stone NA No Observation Yes Current report 76/F Common bile duct stone Yes No Observation Yes M, male; F, female; NA, details not available.

Endoscopy_UCTN_Code_TTT_1AU_2AC

References

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D. Pozo PrietoMD 

Aparato Digestivo
Hospital Universitario Príncipe de Asturias,

Alcalá de Henares,
28805 Madrid,
Spain

Fax: +34-91-8801825

Email: dpozo.hupa@salud.madrid.org