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Vol. 28. Núm. 2.
Páginas 75-80 (Abril - Junio 2016)
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Vol. 28. Núm. 2.
Páginas 75-80 (Abril - Junio 2016)
Case series
DOI: 10.1016/j.endomx.2016.04.001
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Subcapsular hepatic hematoma: An unusual, but potentially life-threating post-ERCP complication. Case report and literature review
Hematoma subcapsular hepático: una complicación post-CPRE poco frecuente pero potencialmente mortal. Reporte de caso y revisión de la literatura
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Armando García Tameza,
Autor para correspondencia
dr.garcia.t93@gmail.com

Corresponding author at: Camino Real 211, El Yerbaniz, Santiago, Nuevo León, Código Postal 67300, Mexico. Tel.: +52 18113126525; fax: +52 7222756375.
, Jorge Alejandro López Cossiob, Guillermo Hernández Hernándeza, María Saraí González Huezod, Ana Alicia Rosales Solísc, Enrique Corona Esquivele
a Médico residente del Servicio de Endoscopia Gastrointestinal, Centro Médico Instituto de Seguridad Social del Estado de México y Municipios (ISSEMyM), Metepec, Estado de México, Mexico
b Médico residente del Servicio de Gastroenterología, Centro Médico Instituto de Seguridad Social del Estado de México y Municipios (ISSEMyM), Metepec, Estado de México, Mexico
c Médico Adscrito al Servicio de Endoscopia Gastrointestinal, Centro Médico Instituto de Seguridad Social del Estado de México y Municipios (ISSEMyM), Metepec, Estado de México, Mexico
d Jefe de Servicio de Gastroenterología, Centro Médico Instituto de Seguridad Social del Estado de México y Municipios (ISSEMyM), Metepec, Estado de México, Mexico
e Médico Adscrito al Servicio de Cirugía General, Centro Médico Instituto de Seguridad Social del Estado de México y Municipios (ISSEMyM), Metepec, Estado de México, Mexico
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Table 1. Hepatic subcapsular hematoma after ERCP summary of cases.
Abstract

Endoscopic retrograde cholangiopancreatography is a very common therapeutic procedure for a variety of biliary and pancreatic duct diseases. Procedure related complications are more frequent than in other endoscopic procedures. The most common reported complications are pancreatitis, bleeding, perforation, and infection. Subcapsular hepatic hematoma secondary to endoscopic retrograde cholangiopancreatography is a rare complication, but is potentially life-threating. The case is presented of a 25 year old patient with choledocholithiasis and cholelithiasis, who developed a subcapsular hepatic hematoma. The patient presented with an acute rupture of Glisson's capsule, which was successfully managed with surgical treatment. A review of the literature is presented, which consists of 30 cases.

Keywords:
Endoscopic retrograde cholangiopancreatography
Complication
Hematoma
Surgery
Resumen

La colangiopancreatografía retrógrada endoscópica es actualmente un procedimiento terapéutico muy común para el manejo de enfermedades biliopancreáticas. Las complicaciones secundarias a este procedimiento son más frecuentes que en otros procedimientos endoscópicos, dentro de las cuales la pancreatitis, hemorragia, perforación e infección son las que se presentan más a menudo. El hematoma hepático subcapsular secundario a colangiopancreatografía retrógrada endoscópica es una complicación muy rara, sin embargo esta puede poner en peligro la vida del paciente. Presentamos el caso de una paciente de 25 años con coledocolitiasis y colelitiasis que desarrolló un hematoma hepático subcapsular poscolangiopancreatografía retrógrada endoscópica con abdomen agudo y ruptura de la cápsula de Glisson que fue manejada exitosamente con tratamiento quirúrgico, así como una revisión de la literatura de 30 casos.

Palabras clave:
Colangiopancreatografía retrógrada endoscópica retrograda
Conducto biliar
Hematoma
Cirugía
Texto completo
Introduction

Endoscopic retrograde cholangiopancreatography (ERCP) is widely available in most hospitals and is one of the most frequently performed procedures in the treatment of biliary–pancreatic diseases. Even in centers with a high-volume of patients that present with biliary and pancreatic pathology and are subsequently treated, serious complications from therapeutic ERCP can occur in 2.5–8% of cases, with mortality ranging from 0.5% to 1.0%.1,2 Acute pancreatitis, cholangitis, hemorrhage, and perforation, the leading complications in 1–7%, 1.4%, 1%, and 1% of patients treated via ERCP respectively.2,3 Subcapsular hepatic hematoma is a rare complication following ERCP and can be life-threatening in some cases.4 The purpose of our study is to present a case of post-ERCP subcapsular hepatic hematoma which evolved with hypovolemic shock and required surgical intervention; we also review the possible pathophysiological mechanisms underlying such complication and analyze the sum of the contemporary available literature (Table 1).

Table 1.

Hepatic subcapsular hematoma after ERCP summary of cases.

Reference  Age  Sex  Guidewire  Procedure  Comorbidity  Diagnostic Method  Hematoma rupture  Onset of symptoms 
De la Serna et al.,1,6,8  71  Yes  Sphyncterotomy+stone extraction  None  CT  No  48
Horn et al.1,6,8  88  Yes  Biliary brushing+stent 10 Fr×7cm  Systemic hypertension+cholecystectomy  NA  No  48
Cardenas et al1,6,8  54  Yes  Sphyncterotomy+stent 10 Fr×7cm  Orthotopic liver transplant  CT  No  24
Gonzalez et al2  30  NA  Spyncterotomy+biliary ballon dilation+stent 10 Fr  None  NA  No  72
Oliveira et al7  84  NA  Stone extraction  COPD+pulmonary thromboembolism+anticoagulation  CT  No  10 days 
Chi et al1,6,8  43  Yes  Sphyncterotomy+metalic stent+biliary balloon dilation 20mm  Cholecystectomy+pancreatic cancer  CT  Yes  5
McArthur et al1,6,8  71  Yes  Sphyncterotomy+stone extraction+stent 7 Fr  None  CT  No  12
Baudet et al1,6  69  Yes  Sphyncterotomy+stone extraction  None  CT  Yes  48
Del Rosi et al9  28  Yes  Sphyncterotomy+stone extraction+stent 10 Fr×10cm  Cholecystectomy  CT  No  48
Carrica et al4  37  Yes  Sphyncterotomy+stone extraction  Cholecystectomy  MRI  No  72
Bartolo et al3  66  NA  Sphyncterotomy+stone extraction  None  NA  No  Immediate 
Priego et al1,6  30  NA  Sphyncterotomy  None  CT  No  Immediate 
Revuelto et al1,6,8  41  NA  NA  Sphyncterotomy+stone extraction  NA  CT  No  NA 
Del Pozo et al1,6  76  Yes  Sphyncterotomy+stone extraction  Atrial fibrillation+anticoagulation  NA  No  6
Bhati et al1,6,8  51  Yes  Sphyncterotomy+stone extraction  None  CT  Yes  Immediate 
Fei et al1,6  56  Yes  Sphyncterotomy+stone extraction  None  CT  No  72
Zizzo et al1  52  Yes  Sphyncterotomy+stone extraction  None  CT  No  24
Klímová et al6  52  Yes  Sphyncterotomy+stone extraction  Chronic pancreatitis  CT  No  6
Perez et al1,6  72  NA  Sphyncterotomy+stone extraction  Diabetes mellitus+systemic hypertension  NA  Yes  2
Orellana et al1  96  NA  NA  Ampullary biopsies+stent  Periampullary tumor  CT  No  4
Orellana et al1,6  49  NA  Biliary stent replacement  Testicular cancer+acute pancreatitis  CT  Yes  2
Orellana et al1,6  55  NA  Biliary stent replacement  Gallbladder cancer  CT  No  NA 
Papachristou et al8  69  Yes  Billiary balloon dilation+brushing+ampullary biopsies+stent  Primary sclerosing cholangitis  CT  NA  48
De Mayo et al8  96  NA  Sphyncterotomy+stent  Acute pancreatitis  CT  No  4
Nari et al1,6,8  15  NA  NA  None  US  No  NA 
Ortega et al1,6,8  81  NA  Sphyncterotomy+stone extraction  NA  NA  NA  NA 
Bhandarkar et al8  64  NA  NA  NA  NA  NA  10 days 
Ertugrul et al1,6,8  41  Yes  Stent  Colangiocarcinoma  CT  No  48
Petit et al1,6,8  98  Yes  Sphyncterotomy+stone extraction  Acute myocardial infarction+parcial gastrectomy sec. to peptic ulcer disease  CT  NA  48
Poon et al10  79  NA  Sphyncterotomy+stent  Stroke+congestive heart failure  CT  No  Immediate 
Case report  25  Yes  Sphyncterotomy+stone extraction  None  US  Yes  12
Reference  Age  Sex  Clinical manifestacions  Treatment  Antibiotics  Hemoglobin decrease (g/dL)  Death 
De la Serna et al.,1,6,8  71  RUC pain  Conservative  Yes  NA  No 
Horn et al.1,6,8  88  RUC pain+anemia  Conservative  Yes  NA  No 
Cardenas et al1,6,8  54  Mesogastric abdominal pain  Conservative  Yes  3.2g/dL  No 
Gonzalez et al2  30  RUC pain  Surgery  Yes  NA  Yes 
Oliveira et al7  84  RUC pain  Percutaneous drainage  Yes  3.3g/dL  Yes 
Chi et al1,6,8  43  RUC pain+anemia  Embolization  Yes  NA  No 
McArthur et al1,6,8  71  RUC pain  Conservative  Yes  NA  No 
Baudet et al1,6  69  RUC pain+fever  Embolization+surgery  Yes CF  7.3g/dL  No 
Del Rosi et al9  28  RUC pain  Conservative  Yes  7.3g/dL  No 
Carrica et al4  37  RUC pain  Percutaneous drainage  Yes CF  1.3g/dL  No 
Bartolo et al3  66  Hypotension+tachycardia  Surgery  No  10.3g/dL  Yes 
Priego et al1,6  30  RUC pain  Surgery  Yes  NA  No 
Revuelto et al1,6,8  41  NA  Anemia  Conservative  Yes  NA  No 
Del Pozo et al1,6  76  RUC pain  Conservative  Yes  NA  No 
Bhati et al1,6,8  51  RUC pain+hypotension  Percutaneous drainage  NA  NA  No 
Fei et al1,6  56  RUC pain  Percutaneous drainage  Yes  NA  No 
Zizzo et al1  52  Epigastric pain  Embolization  Yes  3.3g/dL  No 
Klímová et al6  52  RUC pain  Embolization  Yes  6g/dL  No 
Perez et al1,6  72  RUC pain  Surgery  NA  NA  No 
Orellana et al1  96  NA  Right omalgia  Conservative  Yes  NA  No 
Orellana et al1,6  49  RUC pain  Embolization  NA  NA  No 
Orellana et al1,6  55  RUC pain+right omalgia  Conservative  NA  NA  No 
Papachristou et al8  69  RUC pain+right omalgia+anemia  Conservative  NA  3.5g/dL  NA 
De Mayo et al8  96  Right omalgia  Conservative  Yes  NA  No 
Nari et al1,6,8  15  RUC pain+right omalgia+hypotension  Conservative  Yes  NA  No 
Ortega et al1,6,8  81  RUC pain  Percutaneous drainage  Yes  NA  NA 
Bhandarkar et al8  64  RUC pain+fever+anemia  Percutaneous drainage  NA  NA  NA 
Ertugrul et al1,6,8  41  RUC pain+fever  Conservative  Yes  NA  No 
Petit et al1,6,8  98  RUC pain+asthenia  Percutaneous drainage  NA  NA  NA 
Poon et al10  79  RUC pain+hypotension  Conservative  NA  5g/dL  No 
Case report  25  RUC pain+anemia  Surgery  Yes  4.2g/dL  No 

F – female, M – male, COPD – Chronic Obstructive Pulmonary Disease, RUC – right upper cuadrant, CT – computed tomography, US – ultrasound, MRI – magnetic resonance image, NA – not available, CF – Citrobacter freundii.

Case report

A 25-year-old female with a history of pregnancy and C section 7 months prior to admission presented with recurrent abdominal pain in the upper right quadrant 15 days prior admission, the pain was accompanied by nausea, vomititing, and jaundice. Laboratory report showed the following: WBC 5.51×1.000/μL, Hemoglobin 11.5g/dL, platellet count of 310×1.000/μL, prothrombin time ratio 13.3, international normalized ratio 1.16, aspartate aminotransferase 128U/L, alanine aminotransferase 125U/L, Total Bilirubin 3.57mg/dL, Direct Bilirubin 2.96mg/dL, alkaline phosphatase 928U/L. An MRCP revealed intra and extrahepatic bile duct dilation with a defect in the distal portion of the common bile duct. ERCP with biliary sphincterotomy over a 0.035-inch diameter guidewire was performed, cannulation of the papilla on a first attempt without difficulty following the insertion of a 16mm stone extraction balloon catheter (Shaili Endoscopy®) obtaining one yellow round bile duct stone of 5mm of diameter (Fig. 1), control cholangiography showed no residual defects and the procedure was finished without evident complications such as bleeding or injury. 12h post procedure the patient developed right upper quadrant abdominal pain, hemoglobin dropped 4g/dL (Hb 7.3g/dL), amylase spiked to 162U/L and lipase also showed a rise to 213U/L. There was no clinical evidence of gastrointestinal bleeding. An upper endoscopy was performed with a frontal video endoscope and a duodenoscope without evidence of gastrointestinal bleeding or post-sphyncterotomy bleeding (Fig. 2). Three packed red blood cells (PRBCs) were transfused, and a 12h post transfusional hemoglobin was obtained which reported 10.3g/dL. Hemoglobin declined to 5.3g/dL 3 days after ERCP. The patient developed grade 4 hypovolemic shock with acute abdomen and positive Blumberg sign. An urgent abdominal ultrasound revealed free fluid in the abdominal cavity. Two more PRBCs were transfused and an urgent laparotomy was performed observing rupture of Glisson's capsule (Fig. 3) and approximately 3000ml of blood in the peritoneal cavity was found. Abdominal packing was performed and two more PRBCs were transfused during surgery. The patient was admitted to the Intensive Care Unit (ICU) where she had to have assisted breathing via endotracheal tube. There was no need for vasoactive support. 48h later a second laparotomy was performed to unpack the abdomen. The patient was extubated 6 days after the first laparotomy and was discharged from the ICU. The patient evolved well, maintaining hemoglobin levels at 10.9g/dL and was discharged from the hospital 16 days after the ERCP procedure. One month later a follow-up MRI demonstrated a remanent heterogenic subcapsular hepatic hematoma of 15.2×10.4×3.6cm in the right hepatic lobe (Fig. 4). Currently, the patient is (3 months post ERCP) generally well and reports slight abdominal discomfort, patient surveillance will continue until complete resolution of the hematoma is observed.

Figure 1.

ERCP obtaining one yellow round bile duct stone of 5mm of diameter.

(0,08MB).
Figure 2.

Upper endoscopy with duodenoscope without evidence of bleeding from sphyncterotomy.

(0,09MB).
Figure 3.

Rupture of Glisson's capsule observed in laparotomy.

(0,17MB).
Figure 4.

Subcapsular hepatic hematoma of 15.2×10.4×3.6cm in the right hepatic lobe in magnetic resonance imaging (MRI) one month after presentationT2W sequence on a 1.5-T MRI machine.

(0,14MB).
Discussion

Bleeding related to an ERCP procedure is usually due to endoscopic sphincterotomy. Bleeding seen endoscopically during or immediately after sphincterotomy is not uncommon, but is generally not considered an adverse event unless there is significant blood loss, which is manifested as evident hypovolemia and/or that has a need for transfusion. When applying clinical criteria such as melena, hematemesis, a drop greater than 2g/dL in hemoglobin level, or requirement for secondary intervention such as endoscopy or blood transfusion, the overall incidence of bleeding is around 0.1–2% even in experienced hands.5 Subcapsular hepatic hematoma is a rare and exceptional event, of which only 30 cases have been reported since 2000. The pathophysiologic mechanism underlying the development of the hematoma is not clearly defined, however various authors agree that vascular injury of small-caliber intrahepatic vessels secondary to guidewire use may be the cause, which may also explain the presence of free air and development of infections in some of the cases.1,6

Patient factors

We found that the median age of presentation is 59 (15–98) years, with 58% female and 35% male distribution. Only 2 (6.4%) patients had a history of anticoagulation therapy prior to the procedure. Almost half of the patients (48.3%) presented clinical manifestations in the first 24h post-ERCP. The most common manifestation was abdominal pain in 87%; in some case reports fever was mentioned to be one of the primary manifestations, but we found that right omalgia and clinical manifestations of hypovolemic shock (tachycardia or hypotension) were present more often 9.6% vs 16.1% vs 12.9%.

Procedure factor

In 17 (54.8%) cases the use of a guide wire was reported, but we cannot exclude its use on the other 14 cases. The literature on these 14 cases does not mention the use of a guide wire.

In most of the cases, 67.7%, diagnosis was performed by CT, but the use of US and MRI was also described in 2 and 1 cases respectively. In our case report abdominal US was performed searching for free fluid in the abdominal cavity, because of the development of an acute abdomen. In almost half of the patients (45.1%) no invasive treatment was required. Percutaneous drainage was performed in 7 (22.5%), surgery in 6 (19.3%), and embolization in 4 (12.9%) patients. Only 2 case reports described the pathogen found in the hematoma culture, both found Citrobacter freundii, which is a facultative aerobic gram-negative bacilli of the Enterobacteriaceae family, commonly found in the gastrointestinal tract. In 22 (70.9%) patients antibiotics where used, either as a prophylactic measure or as treatment for infection, 8 (25.8%) did not specify whether they used antibiotics or not. Only 11 case reports mention a decrease in hemoglobin that went between 1.3g/dL to 10.3g/dL, and from those cases, the majority, 63%, required some kind of intervention (embolization, percutaneous drainage or surgery), concluding that hemoglobin decrease is a good predictor for requiring intervention, no association was found between hemoglobin drop and the need of a specific kind of intervention. 3 (9.6%) deaths were reported, 2 patients who required surgery and one in whom percutaneous drainage was performed.

Because of the mortality rate found in the literature it is important to consider this as a life-threatening adverse event. Another rare complication following ERCP that can have a similar presentation as described in the case report is injury to the spleen causing intraperitoneal hemorrhage with a few cases being reported in the literature. Symptoms often include localized peritoneal irritation in the left upper quadrant progressing with time to generalized peritonitis, along with referred pain to the left shoulder. Changes in vital signs including tachycardia and orthostatic changes in blood pressure are frequent.

Conclusions

Subcapsular hepatic hematoma is a rare condition associated to ERCP that must be suspected when abdominal pain is present after the procedure, it may have a fatal course if it is not diagnosed and treated early. Further publications of case reports will help establish risk factors and appropriate treatment.

Financing

No funding was received for this work.

Conflict of interests

Authors declare no conflict of interests for this article.

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