Case Report
Copyright ©The Author(s) 2016. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastroenterol. May 7, 2016; 22(17): 4411-4415
Published online May 7, 2016. doi: 10.3748/wjg.v22.i17.4411
Subcapsular hepatic haematoma of the right lobe following endoscopic retrograde cholangiopancreatography: Case report and literature review
Marco Antonio Zappa, Alberto Aiolfi, Ilaria Antonini, Cinzia Domenica Musolino, Andrea Porta
Marco Antonio Zappa, Alberto Aiolfi, Ilaria Antonini, Cinzia Domenica Musolino, Andrea Porta, University of Milan, Department of General and Emergency surgery, Ospedale S Famiglia Fatabenefratelli, 22036 Erba, Italy
Author contributions: Zappa MA, Aiolfi A and Porta A contributed to study concept/design, data collection, data analysis, data interpretation, writing the paper; Antonini I and Musolino CD contributed to data collection.
Institutional review board statement: This case report was exempt from the Institutional Review Board standards at University of Milan.
Informed consent statement: The patient involved in this study gave written informed consent authorizing use and disclosure of personal protected health information.
Conflict-of-interest statement: Marco Antonio Zappa, Alberto Aiolfi, Ilaria Antonini, Cinzia Domenica Musolino and Andrea Porta declare no conflicts of interests.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Correspondence to: Marco Antonio Zappa, Professor, Department of General and Emergency surgery, Ospedale S Famiglia Fatabenefratelli, Via Fatebenefratelli, 20, 22036 Erba, Italy. marcoantonio.zappa@libero.it
Telephone: +39-31-638359
Received: December 11, 2015
Peer-review started: December 11, 2015
First decision: January 13, 2016
Revised: January 26, 2016
Accepted: February 22, 2016
Article in press: February 22, 2016
Published online: May 7, 2016

Abstract

Sub capsular hepatic haematoma is a rare complication after endoscopic retrograde cholangiopancreatography (ERCP). Exact pathological mechanism is still unclear and few reports are nowadays available in literature. We report the case of a 58-year-old woman with recurrent episodes of upper abdominal pain, nausea and vomiting. On the basis of laboratory exams, abdomen ultrasound and magnetic resonance imaging she was diagnosed with a common bile duct stone. Endoscopic biliary sphincterotomy was performed. On the following day the patient complaint severe abdominal pain with rebound and hemodynamic instability. A computed tomography scan reveal a 14 cm × 6 cm × 19 cm sub-capsular hepatic haematoma on the right lobe that was successfully managed via percutaneous embolization. Sub capsular liver haematoma is a rare life threatening complication after ERCP that should be managed according to patients’ haemodynamic and clinic.

Key Words: Endoscopic guidewire, Endoscopic retrograde cholangiopancreatography, Abdominal pain, Subcapsular hepatic hematoma, Embolization

Core tip: Hepatic hematoma is a rare and potentially life threatening complication after endoscopic retrograde cholangiopancreatography (ERCP). Despite its severity, only few cases are described in current literature. The paper describe the management of a huge right lobe hepatic hematoma following ERCP. An exhaustive literature analysis is made considering, signs and symptoms at presentation, time of presentation, diagnosis, and treatment. Awareness of this potential complication, high level of suspicion and prompt treatment are at the basis of better outcomes in such patients.


Citation: Zappa MA, Aiolfi A, Antonini I, Musolino CD, Porta A. Subcapsular hepatic haematoma of the right lobe following endoscopic retrograde cholangiopancreatography: Case report and literature review. World J Gastroenterol 2016; 22(17): 4411-4415
INTRODUCTION

Endoscopic retrograde cholangiopancreatography (ERCP) is a minimally invasive procedure for diagnosis and treatment of biliary and pancreatic disease. Complications occur in 2.5%-8% of cases with mortality rates ranging from 0.5%-1.0%[1]. Pancreatitis, cholangitis, perforation, and bleeding as a result of papillotomy are the most frequently described complications[2-3]. Sub capsular hepatic haematoma is a rare and potential life threatening condition[4]. We report the unusual case of a sub capsular hepatic haematoma after ERCP presenting with abdominal pain and hypotension.

CASE REPORT

A 58-year-old woman with recurrent episodes of upper abdominal pain was diagnosed with common bile duct stone by abdomen ultrasound and magnetic resonance imaging. She was admitted for ERCP and sphincterotomy. A proper drainage of the common bile duct was performed without complications. 12 h after the procedure the patient complaint a sudden abdominal pain with tenderness and rebound in the upper right quadrant without fever. Laboratory tests revealed a normal white blood cell count (7.44 × 109/L) and haemoglobin level (13.3 g/dL) with a slightly increased C-reactive protein (14.3 mg/dL). Total bilirubin, transaminases and amylases were within normal limits. Abdomen plain film was normal without signs of pneumoperitoneum. On the basis of such symptoms the patient was closely monitored. On the following 12 h she gradually develops hypotension (95/50 mmHg) and tachycardia (115 bpm) with a progressive haemoglobin decrease (8.6 g/dL). Urgent abdomen computed tomography (CT) scan demonstrated a large subcapsular hepatic haematoma of the right hepatic lobe supported by three peripheral parenchymal lacerations with contextual active bleeding and compression of the right and middle hepatic vein (Figure 1). On the basis of laboratory, clinical, and hemodynamic parameters the patient was urgently managed with percutaneous embolization of some small peripheral vessels on the sixth and seventh segment.

Figure 1
Figure 1 Urgent abdomen computed tomography scan. A: Hepatic subcapsular hematoma of the right lobe (14 cm × 6 cm × 19 cm) with peripheral parenchymal laceration. Ab-extrinsic compression of the right and middle hepatic vein with perisplenic free fluid; B: Six days after radiological selective embolization: note the stability of the haematoma dimension with disappearance of perisplenic free fluid.

The post procedural course was uneventful with restoration of normal haemoglobin levels after transfusion (12.9 g/dL). Six days after embolization an abdomen CT scan shows the stability of the hematoma and the patient was discharged home.

DISCUSSION

Sub capsular hepatic haematoma is a rare and potentially life threatening complication after ERCP. Probably underestimated, only few cases are nowadays reported in literature and the exact pathological mechanism is unclear (Table 1). Accidental puncture of a peripheral intrahepatic biliar tree with consensual laceration of a small parenchymal vessels by endoscopic guide wire, may explain the phenomenon[2-4].

Table 1 Subcapsular hepatic haematoma following endoscopic retrograde cholangiopancreatography: Review of the literature.
Ref.Indication for ERCPERCPOnset of symptomsSymptomsDiagnosisDimensionTreatmentDeath
Ortega Deballon et al[5]Common bile duct stoneNANAAbdominal painNANAPercutaneous drainageNo
Horn et al[6]Pancreatic adenocarcinomaCytologic brushing over a 0.035-inch guidewire + biliary stent48 hAbdominal pain/anemia48 h; CT scanNA (right lobe)ConservativeNo
Chi et al[7]Pancreatic cancerBiliary stent placement over a guidewireNAAbdominal painNANAEmbolizationNo
Ertuğrul et al[8]Hilar cholangiocarcinomaBiliary stent placement over a guidewire48 hAbdominal pain/fever48 h, CT scan7.8 cm × 4.1 cm (right lobe)ConservativeNo
Priego et al[9]Common bile duct stoneSpincterotomy over a guidewireNAAbdominal pain/hypotension/peritonismNA, CT scan4.7 cm × 10 cm × 11 cm (right lobe)Surgery (Haematoma evacuation)No
Petit-Laurent et al[10]Common bile duct stoneSpincterotomy over a guidewire48 hAbdominal pain/fever48 h; US/CT scanNAPercutaneous drainageNo
Bhati et al[11]Common bile duct stoneSpincterotomy over a guidewireNAAbdominal pain/hypotensionNA; CT scan10 cm × 13 cm (right lobe)Percutaneous drainageNo
Mc Arthur et al[12]Common bile duct stoneSpincterotomy over a 0.035-ich guidewire + biliary stent12 hAbdominal pain/leucocytosis12 h; CT scan5 cm × 3 cm (right lobe)ConservativeNo
De La Serna-Higuera et al[13]Common bile duct stoneSpincterotomy over a 0.035-ich guidewire48 hAbdominal pain/leucocytosis72 h; abdomen US/ CT scan14 cm × 8 cm × 5 cm (right lobe)ConservativeNo
Cárdenas et al[14]bile leak after liver transplantationSpincterotomy over a guidewire + biliary plastic stent positioning24 hAbdominal pain/anemiaNA, CT scanNAConservativeNo
Nari et al[15]Acute biliary pancreatitisNANAFever/Abdominal painNA; CT scanNA (right lobe)ConservativeNo
Revuelto Rey et al[16]Common bile duct stoneSpincterotomy6 hAnemia6 hours; CT scan13 cm × 9 cm × 11 cm (right lobe)ConservativeNo
Baudet et al[17]Common bile duct stoneSpincterotomy over a 0.035-ich guidewire24 hAbdominal pain/anemia/fever/hypotension36 h; abdomen US/CT scan16 cm × 6 cm, 5 cm × 21 cm (right lobe S6-7-8)Embolization/surgery (haematoma evacuation)No
Pérez-Legaz et al[18]Common bile duct stoneSpincterotomy2 hAbdominal pain/anemia/hypotension/peritonism2 h; CT scan8 cm (S5-6)Surgery (electrocoagulation)No
Del Pozo et al[19]Common bile duct stoneSpincterotomy over a 0.035-ich guidewire6 hAbdominal pain5 d; CT scanNA, Right lobeConservativeNo
Orellana et al[4]Periampullary tumorBiopsies + biliary plastic stent4 hAbdominal pain4 h, CT scan17 cm × 13 cm × 5 cm (right lobe)ConservativeNo
Biliary stent occlusionStent exchange2 hAbdominal pain/hypotension2 h; CT scanHepatic hematoma covering the 50% of the total hepatic volume + hemoperitoneumEmbolization of the right epatic artery + peritoneal drainage under CT guidance under CT guidanceNo
Biliary stent disfunction in a patient affected by gallbladder cancer with consensual malignant biliary obstructionBiliary plastic stent exchangeNAAbdominal painNA, CT scanHepatic hematoma covering the 30% of the total hepatic volumeConservativeNo
Fei et al[1]Common bile duct stoneSpincterotomy over a 0.035-ich guidewire2 hFever6 d; CT scan13 cm × 6 cm (right lobe)Percutaneous drainageNo
Klímová et al[20]Wirsung stoneNA6 hAbdomial pain/anemia/hypotensionNARight lobeEmbolization/surgery/percutaneous drainageNo
Zizzo et al[21]Common bile duct stoneSpincterotomy over a 0.035-ich guidewire24 hAbdominal pain/hypotension/anemia36 h; CT scan and angiography15 cm × 11 cm (right lobe)EmbolizationNo
González-López et al[22]Iatrogenic benign stenosis following laparoscopic cholecistecotmySpincterotomy + Pneumatic dilation + biliary stent positioning24 hAbdominal pain/anemia/hypotension/peritonism72 h; CT scanNA (right lobe)Surgery (damage control and packing)Yes
Present case 2015Common bile duct stoneSpincterotomy over a 0.035-ich guidewire12 hAbdominal pain/hypotension/anemia24 h; CT scan14 cm × 6 cm × 19 cm (right lobe)EmbolizationNo

Sudden abdominal pain whenever associated with hypotension and tachycardia after ERCP should raise the suspicion of intrahepatic bleeding with Glisson’s capsule distension. Different symptoms are described in literature: abdominal pain (91%), anemia (39.1%), hypotension (39.1%), fever (21.7%) and peritonism (13%) (Table 1). Laboratory tests did not provide major indicators of the development of a sub capsular hepatic haematoma, except for a decrease in the haemoglobin level[1]. Imaging modalities (ultrasound and CT) are the gold standard for diagnosis and surveillance of this emergent complication[9,15].

In the present case symptoms and signs started 12 h after the procedure with an early diagnosis and prompt treatment. Aspecific symptoms with a late onset from ERCP may occur with consequent delayed diagnosis and treatment (range 2-144 h) (Table 1).

Different treatment modalities are proposed in literature based on haemodynamic and clinics. The role of imaging in the assessment dimension and of ab extrinsic compression on hepatic vein is an important detail that should kept in mind whenever approaching such patients.

In stable patients with a limited, peripheral and non-compressive haematoma, a conservative management with prophylactic antibiotics should be suggested. Serial haemoglobin controls and abdomen CT verification is advisable[19]. Percutaneous drainage under CT guide and US should be proposed in case of abscess formation and fever[1].

Whenever hemodynamic instability is present with active bleeding and contrast extravasation, an immediate radiological or surgical approach should be taken into account. Minimally invasive radiological selective peripheral vessels embolization shows high success rates[21]. Surgical management should be reserved in case of general condition deterioration, haemodynamic instability with signs of consensual peritoneal and free abdominal fluid[9]. Surgical approach consist in hematoma evacuation, local haemostasis with electrocoagulation or haemostatic devices, or packing in case of massive haemorrhage[22]. Literature data are in favour with a conservative treatment (43.5%), percutaneous embolization (26%), drainage (17.4%) and surgical management (13%) as a first line treatment. Failure of the first approach occur in 3 different cases (13%) without severe consequences (Table 1). Sudden rupture of the haematoma with consequent haemoperitoneum is a dreaded complications with high risk of mortality if misdiagnosed. González-López et al[22] report the case of a 30 years-old patient with Glisson’s capsule rupture and consequent haemoperitoneum with consequent hypotension and signs of peritonism. The patients was surgically managed with electrocautery and packing without success.

Sub capsular liver haematoma is a rare and potentially life threatening complication following ERCP. Conservative treatment will be sufficient in most hemodinamically stable patients with no signs of super infection or abscess formation. Selective embolization is adequate in case of peripheral small vessels bleeding determining hemodynamic instability. Surgical approach is advisable in case of rupture risk, signs of peritonism and free abdominal fluid. Serial follow up CT scan are essential for dimension monitoring. We recommend that for legal purposes this potential risk should be addressed in the preoperative informed consent.

COMMENTS
Case characteristics

A 58-year-old woman with recurrent episodes of upper abdominal pain was diagnosed with common bile duct stone by abdomen ultrasound and magnetic resonance imaging and admitted for endoscopic retrograde cholangiopancreatography (ERCP) and sphincterotomy.

Clinical diagnosis

Hemodynamic instability, hypotension, and tachycardia were consistent with a post-procedural bleeding.

Differential diagnosis

Papillary bleeding after ERCP is one of the most common complications after the procedure. Splenic rupture, intrahepatic hematoma and visceral abdominal vessels rupture, related to instrumental looping with excessive traction, are exceptionally responsible for such situation.

Laboratory diagnosis

Laboratory tests did not provide major indicators in development of sub capsular hepatic haematoma.

Imaging diagnosis

Abdominal ultrasound and computed tomography (CT) scan are necessary for differential diagnosis.

Pathological diagnosis

A large sub capsular hepatic haematoma of the right lobe with active bleeding was evident on CT scan.

Treatment

On the basis of laboratory, clinical, and hemodynamic parameters the patient was urgently managed with percutaneous embolization of some small peripheral vessels.

Related reports

Probably underestimated, hepatic hematoma following ERCP is an extremely rare complication with few cases reported in current literature.

Experiences and lessons

Hepatic hematoma is a rare, potentially life threatening complication after ERCP. Awareness of such event is fundamental for early detection, diagnosis and treatment.

Peer-review

This report describe our experience in the management of a large hepatic hematoma after ERCP with an exhaustive literature review. Symptoms and signs at presentation, diagnosis, and management are reviewed in accordance to published literature. Limited number of literature reported cases is the major weakness of this study. Further studies are necessary to investigate the mechanism of injury and appropriate management of such complication.

Footnotes

P- Reviewer: Alimehmeti R, Djodjevic I S- Editor: Qi Y L- Editor: A E- Editor: Wang CH

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