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Vol. 42. Issue 1.
Pages 23-27 (January 2019)
Vol. 42. Issue 1.
Pages 23-27 (January 2019)
Scientific letter
DOI: 10.1016/j.gastre.2019.01.003
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Subcapsular hepatic haematoma after endoscopic retrograde cholangiopancreatography. A rare complication with high morbidity and mortality
Hematoma subcapsular hepático tras colangiopancreatografía retrógrada endoscópica. Una complicación rara y con elevada morbimortalidad
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Jon de la Maza Ortiza,
Corresponding author
maza_jon@hotmail.com

Corresponding author.
, Seila García Mulasa, Juan Carlos Ávila Alegríaa, Javier García Lledóa, Leticia Pérez Carazoa, Beatriz Merino Rodrígueza, Manuel González Leyteb, Óscar Nogalesa
a Servicio de Aparato Digestivo, Hospital General Universitario Gregorio Marañón, Madrid, Spain
b Sección de Radiología Vascular e Intervencionista, Servicio de Radiología, Hospital General Universitario Gregorio Marañón, Madrid, Spain
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Table 1. Reported cases of subcapsular hepatic haematoma after ERCP.
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Endoscopic retrograde cholangiopancreatography (ERCP) is an essential technique in the treatment of biliary and pancreatic disease. The overall complication rate of ERCP is approximately 6.9%.1 The development of a subcapsular hepatic haematoma is an uncommon event, although it is probably underdiagnosed. In most cases the outcome is favourable, but vascular embolisation and/or surgical intervention can be necessary.2

We first present the case of a 35-year-old woman referred with acute cholangitis secondary to choledocholithiasis. The patient had normal coagulation (platelets 181,000/μl and INR 0.95). ERCP was performed with selective channelling of the bile duct using a hydrophilic guidewire (Hydra Jagwire™, Boston Scientific, USA). The cholangiogram showed an extrahepatic bile duct measuring 15mm with multiple filling defects. After performing a biliary sphincterotomy and sphincteroplasty with balloon dilation using a CRE™ balloon (Boston Scientific, USA) of 15mm diameter for 1min, all stones were extracted with a Fogarty balloon (Extractor™ Pro, Boston Scientific, USA). Four hours later, the patient developed hypotension, decreased level of consciousness and anaemia, with haemoglobin of 6.9g/dl. Abdominal CT with intravenous contrast (IVC) identified a subcapsular haematoma measuring 140×45mm in the right lobe of the liver (RLL). The patient made a good recovery with conservative treatment, including antibiotic therapy, and was discharged after 18 days. A follow-up CT scan at four months showed a decrease in the size of the haematoma (49×22mm).

Next, we present the case of a 54-year-old woman with previous cholecystectomy admitted for choledocholithiasis with dilation of the bile duct. The patient had normal coagulation (platelets 233,000/μl and INR 0.94). An ERCP was performed where a papilla was visualised with previous sphincterotomy, the bile duct was selectively cannulated with sphincterotome, and multiple biliary casts were extracted. Two hours later, the patient developed abdominal pain, hypotension and anaemia with haemoglobin of 5.6g/dl with Fogarty balloon. Abdominal CT with IVC showed a subcapsular haematoma in the RLL (170×40×150mm) and a leak of contrast at that location, suggestive of active bleeding. As the bleeding was not confirmed by selective arteriogram, conservative treatment was maintained (transfusion, IV fluids and broad-spectrum antibiotic therapy). At 72h, the patient had a recurrence of the bleeding and abdominal CT with IVC showed that the haematoma had grown in size (100×120×190mm), with findings (Fig. 1) suggestive of active bleeding in segment V. In a repeat angiographic study, multifocal active punctate arterial bleeding was confirmed on the surface of the RLL (in relation to rupture of (Fig. 1) small vessels between the liver surface and the capsule after primary distension due to the initial haematoma) associated with severe vasospasm of the right hepatic artery, which was resolved with glyceryl trinitrate and embolisation with Spongostan® particles. As with the first case, she made a good recovery.

Figure 1.

(A) CT: image showing subcapsular hepatic haematoma measuring 100×120×190mm. (B) Arteriogram: treatment by vascular embolisation.

(0.12MB).

The most common haemorrhagic complication after an ERCP is post-sphincterotomy bleeding (1.3%).1 One complication within this subgroup which is underdiagnosed is intrahepatic bleeding, leading to the formation of a subcapsular hepatic haematoma, predominantly in the RLL.

The aetiopathogenic mechanism is not fully understood. The main theory suggests the presence of a mechanical component associated with the use of the guidewire, which would seem to cause trauma in the biliary tree and adjacent small intrahepatic vessels.3 In some cases, it seems to be associated with the traction caused by the endoscope itself or by the Fogarty balloon.4 In terms of the distribution of the haematoma, it is suggested that this is determined by the filtering of blood through the hepatic parenchyma in a centrifugal direction, and the pathophysiology is completed by the presence of a solid hepatic capsule containing the haematoma.5

Up to 2016, 42 cases had been documented in the literature (Table 1). There are no significant differences in terms of gender or age, and choledocholithiasis is the most common indication. In most cases, the onset of symptoms occurs in the first 48h and abdominal pain is the predominant manifestation. Management is usually conservative, with surgery required in less than 30% of cases. Morbidity and mortality rates may be overestimated given that the documented cases are probably more serious and many cases are pauci-symptomatic.

Table 1.

Reported cases of subcapsular hepatic haematoma after ERCP.

Author  Age  Gender  Indication  Guidewire  ERCP  Start  Signs and symptoms  Clotting  Size (mm)  Haematoma infection  Antibiotic  Treatment  Death 
Ortega-Deballon et al.,6 2000  81  Lithiasis  NA  Sphincterotomy, extractor balloon  NA  Pain  NA  NA  Yes  Yes  PD  No 
Chi et al.,7 2004  43  Pancreatic cancer  Yes  Sphincterotomy, metal prosthesis  5Pain, anaemia  Normal  80×150  No  Yes  Embolisation  No 
Horn et al.,3 2004  88  Pancreatic cyst  Yes  Sphincterotomy, plastic prosthesis, cytology  48Pain, anaemia  Normal  NA  No  Yes  Conservative  No 
Ertugrul et al.,8 2006  41  CholangioCa  Yes  Plastic prosthesis  48Pain, pyrexia  Normal  78×41  No  Yes  Conservative  No 
Priego et al.,9 2007  30  Obstructive jaundice  Yes  Sphincterotomy  NA  Pain, LBP  Normal  47×100×110  Yes  Yes  Surgery  No 
Bhati et al.,10 2007  51  Lithiasis  Yes  Sphincterotomy, extractor balloon  NA  Pain, LBP  Normal  100×130  No  NA  PD  No 
Petit-Laurent et al.,11 2007  98  Lithiasis  Yes  Sphincterotomy, extractor balloon  48NA  Normal  NA  No  NA  PD  No 
Del-Rossi et al.,12 2007  28  Lithiasis  Yes  Sphincterotomy, prosthesis  48Pain, LBP, anaemia  Normal  120×160  No  Yes  Conservative  No 
Papachristou et al.,13 2007  69  CholangioCa  Yes  Sphincteroplasty, plastic prosthesis, cytology, biopsy  48Pain, anaemia  Normal  169×150×70  No  NA  Conservative  NA 
McArthur et al.,14 2008  71  Lithiasis  Yes  Sphincterotomy, extractor balloon, plastic prosthesis  12Pain, leucocytosis  NA  50×30  No  Yes  Conservative  No 
De la Serna-Higuera et al.,15 2008  71  Lithiasis  Yes  Sphincterotomy, extractor balloon  48Pain, leucocytosis  Normal  140×80×50  No  Yes  Conservative  No 
Cárdenas et al.,16 2008  54  Bile leak post OLT  Yes  Sphincterotomy, plastic prosthesis  24Pain, anaemia  Abnormal  90×20  No  Yes  Conservative  No 
De Mayo et al.,17 2008  96  Ampullary carcinoma  NA  Sphincteroplasty  4Pain  NA  170×130×50  No  Yes  Conservative  No 
Yrribery-Ureña et al.,18 2009  46  Lithiasis  Yes  Sphincterotomy, extractor balloon  48Pain, anaemia  NA  NA  NA  NA  Surgery  NA 
Nari et al.,19 2009  15  Pancreatitis  NA  NA  NA  Pain, pyrexia  NA  135×49×35  No  Yes  Conservative  No 
Saa et al.,20 2010  92  NA  Lithiasis  NA  Sphincterotomy  24Anaemia  NA  NA  Yes  NA  PD+surgery  Yes 
Revuelto Rey et al.,21 2010  41  Lithiasis  NA  Sphincterotomy  6Pain, anaemia  NA  130×90×110  NA  Yes  Conservative  No 
Baudet et al.,4 2011  69  Lithiasis  Yes  Sphincterotomy, extractor balloon  4Pain, anaemia, pyrexia, LBP  NA  160×65×21  Yes  Yes  Embolisation+surgery  No 
Pérez-Legaz et al.,22 2011  72  Lithiasis  NA  Sphincterotomy  2Pain, anaemia, LBP  NA  80  NA  NA  Surgery  No 
Del Pozo et al.,23 2011  76  Lithiasis  Yes  Sphincterotomy, extractor balloon  5Pain  Abnormal  NA  NA  Yes  Conservative  No 
Orellana et al.,24 2012  96  Periampullary tumour  Yes  Plastic prosthesis, biopsies  4Pain  NA  170×130×50  NA  Yes  Conservative  No 
Orellana et al.,24 2012  49  Occlusion of biliary prosthesis  Yes  Plastic prosthesis  2Pain, LBP  NA  50% of liver volume  NA  NA  Embolisation+PD  No 
Orellana et al.,24 2012  55  Dysfunction of bile duct prosthesis  Yes  Plastic prosthesis  NA  Pain  NA  30% of liver volume  NA  NA  Conservative  No 
Bartolo-Rangel et al.,25 2012  62  Cholangitis  Yes  Sphincterotomy, extractor balloon  NA  LBP, anaemia  Normal  NA  NA  NA  Surgery  Yes 
Patil et al.,26 2013  50  Cholangitis  Yes  Sphincterotomy, extractor balloon  48Pain  NA  50×30  No  Yes  PD  No 
Oliveira-Ferreira et al.,27 2013  84  Lithiasis  Yes  Extractor balloon  10Pain, anaemia  Abnormal  90×100  Yes  Yes  PD  Yes 
Fei et al.,28 2013  56  Lithiasis  Yes  Sphincterotomy, basket  2Pyrexia  NA  130×60  NA  Yes  PD  No 
Carrica et al.,29 2014  37  Lithiasis  Yes  Sphincterotomy  72Pain, anaemia, pyrexia  NA  124×93  Yes  Yes  PD  No 
Yoshii et al.,30 2014  86  Lithiasis  NA  Lithotripsy and extraction in 4 sessions  30Pain  NA  NA  NA  Yes  Conservative  No 
González-López et al.,2 2015  30  Benign choledochal stenosis  Yes  Sphincterotomy, choledochal dilation, biliary prosthesis  NA  Pain, anaemia, LBP  NA  NA  NA  NA  Surgery  Yes 
Klìmovà et al.,31 2014  54  Pancreatic lithiasis  Yes  Biliary and pancreatic sphincterotomy  6Pain, anaemia, LBP  NA  190×178×69  Yes  Yes  Embolisation+surgery+PD  No 
Solmaz et al.,32 2016  55  Lithiasis  Yes  Sphincterotomy, extractor balloon  6Pain  Normal  140×67  No  Yes  Conservative  No 
Servide et al.,33 2016  83  Cholangitis  NA  NA  15Pain  NA  NA  NA  NA  Conservative  No 
Zizzo et al.,5 2015  52  Lithiasis  Yes  Sphincterotomy, nasobiliary drainage  24Pain, anaemia, LBP  Normal  150×110  NA  NA  Embolisation  No 
Zappa et al.,34 2016  58  Lithiasis  Yes  Sphincterotomy  12Pain, anaemia, LBP  NA  140×60×190  NA  NA  Embolisation  No 
Kilic et al.,35 2016  69  Lithiasis  NA  Sphincterotomy, extractor balloon, basket  12Pain, LBP  Normal  40×20  Yes  Yes  Surgery+PD  No 
Curvale et al.,36 2016  78  Choledochal adenoma  Yes  Sphincterotomy, extractor balloon, basket, polypectomy  1Pain, anaemia, LBP  Normal  NA  NA  NA  Surgery  No 
Fiorini et al.,37 2016  47  Lithiasis  Yes  Sphincterotomy, extractor balloon  8Pain, pyrexia  NA  45×45  Yes  Yes  PD  No 
Areopaja Escobar et al.,38 2016  47  NA  Lithiasis  Yes  Sphincterotomy+prosthesis  10Pain  NA  NA  NA  Yes  PD  No 
Tamez et al.,39 2016  25  Lithiasis  Yes  Sphincterotomy, extractor balloon  12Pain, anaemia, LBP  Normal  152×104×36  NA  NA  Surgery  No 
Present case 1  35  Lithiasis  Yes  Sphincterotomy, sphincteroplasty, extractor balloon  <12Anaemia, LBP, drowsiness  Normal  140×45  No  Yes  Conservative  No 
Present case 2  54  Lithiasis  Yes  Extractor balloon (sphincterotomy previously)  2Pain, anaemia, LBP  Normal  100×120×190  No  Yes  Embolisation  No 

CholangioCa: cholangiocarcinoma; ERCP: endoscopic retrograde cholangiopancreatography; d: days; h: hours; PD: percutaneous drainage; F: female; M: male; LBP: low blood pressure (hypotension); OLT: orthotopic liver transplant; NA: not available in the article.

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Please cite this article as: de la Maza Ortiz J, García Mulas S, Ávila Alegría JC, García Lledó J, Pérez Carazo L, Merino Rodríguez B, et al. Hematoma subcapsular hepático tras colangiopancreatografía retrógrada endoscópica. Una complicación rara y con elevada morbimortalidad. Gastroenterol Hepatol. 2019;42:23–27.

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