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

Competing interests: None

References

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