Subcapsular hepatic hematoma: An unusual, but potentially life-threating post-ERCP complication. Case report and literature review

Endoscopia.2016;28(2):75---80

www.elsevier.es/endoscopia

ENDOSCOPIA

CASE

SERIES

Subcapsular

hepatic

hematoma:

An

unusual,

but

potentially

life-threating

post-ERCP

complication.

Case

report

and

literature

review

夽

Armando

García

Tamez

_,

_Jorge

_Alejandro

_López

_Cossio

_,

Guillermo

Hernández

Hernández

_,

_María

_Saraí

_González

_Huezo

_,

Ana

Alicia

Rosales

Solís

_,

_Enrique

_Corona

_Esquivel

a_{MédicoresidentedelServiciodeEndoscopiaGastrointestinal,CentroMédicoInstitutodeSeguridadSocialdelEstadodeMéxico} yMunicipios(ISSEMyM),Metepec,EstadodeMéxico,Mexico

b_{MédicoresidentedelServiciodeGastroenterología,CentroMédicoInstitutodeSeguridadSocialdelEstadodeMéxicoy} Municipios(ISSEMyM),Metepec,EstadodeMéxico,Mexico

c_{MédicoAdscritoalServiciodeEndoscopiaGastrointestinal,CentroMédicoInstitutodeSeguridadSocialdelEstadodeMéxicoy} Municipios(ISSEMyM),Metepec,EstadodeMéxico,Mexico

d_{JefedeServiciodeGastroenterología,CentroMédicoInstitutodeSeguridadSocialdelEstadodeMéxicoyMunicipios} (ISSEMyM),Metepec,EstadodeMéxico,Mexico

e_{MédicoAdscritoalServiciodeCirugíaGeneral,CentroMédicoInstitutodeSeguridadSocialdelEstadodeMéxicoyMunicipios} (ISSEMyM),Metepec,EstadodeMéxico,Mexico

Received10December2015;accepted1April2016 Availableonline15July2016

KEYWORDS Endoscopic retrograde cholan-giopancreatography; Complication; Hematoma; Surgery

Abstract Endoscopicretrogradecholangiopancreatographyisaverycommontherapeutic pro-cedureforavarietyofbiliaryandpancreaticductdiseases.Procedurerelatedcomplicationsare morefrequentthaninotherendoscopicprocedures.Themostcommonreportedcomplications are pancreatitis, bleeding, perforation, and infection. Subcapsularhepatic hematoma sec-ondary to endoscopic retrograde cholangiopancreatography is a rare complication, but is potentiallylife-threating.Thecaseispresentedofa25yearoldpatientwithcholedocholithiasis andcholelithiasis,whodevelopedasubcapsularhepatichematoma.Thepatientpresentedwith

夽 _{Endoscopymagazineistheonlymagazineinwhichtheworkunderreviewispublished.}

∗_{Correspondingauthorat:CaminoReal211,ElYerbaniz,Santiago,NuevoLeón,CódigoPostal67300,Mexico.Tel.:+5218113126525;}

fax:+527222756375.

E-mailaddress:dr.garcia.t93@gmail.com(A.GarcíaTamez). http://dx.doi.org/10.1016/j.endomx.2016.04.001

0188-9893/©2016ASOCIACI´ONMEXICANADEENDOSCOPIAGASTROINTESTINALA.C.PublishedbyMassonDoymaM´exicoS.A.Thisisanopen accessarticleundertheCCBY-NC-NDlicense(http://creativecommons.org/licenses/by-nc-nd/4.0/).

76 A.GarcíaTamezetal. anacuteruptureofGlisson’scapsule,whichwassuccessfullymanagedwithsurgicaltreatment. Areviewoftheliteratureispresented,whichconsistsof30cases.

©2016ASOCIACI´ONMEXICANADEENDOSCOPIAGASTROINTESTINAL A.C.PublishedbyMasson Doyma M´exico S.A. This is an openaccess article under the CC BY-NC-ND license(http:// creativecommons.org/licenses/by-nc-nd/4.0/). PALABRASCLAVE Colangiopancre-atografíaretrógrada endoscópica retrograda; Conductobiliar; Hematoma; Cirugía

Hematomasubcapsularhepático:unacomplicaciónpost-CPREpocofrecuentepero potencialmentemortal.Reportedecasoyrevisióndelaliteratura

Resumen La colangiopancreatografía retrógrada endoscópica es actualmente un proced-imiento terapéutico muy común para el manejo de enfermedades biliopancreáticas. Las complicacionessecundariasaesteprocedimientosonmásfrecuentesqueenotros procedimien-tosendoscópicos,dentrodelascualeslapancreatitis,hemorragia,perforacióneinfecciónson lasquesepresentanmásamenudo.Elhematomahepáticosubcapsularsecundarioa colan-giopancreatografíaretrógrada endoscópicaesunacomplicaciónmuyrara, sinembargoesta puedeponerenpeligrolavidadelpaciente.Presentamoselcasodeunapacientede25a˜noscon coledocolitiasisycolelitiasisquedesarrollóunhematomahepáticosubcapsular poscolangiopan-creatografíaretrógradaendoscópicaconabdomenagudoyrupturadelacápsuladeGlissonque fuemanejadaexitosamentecontratamientoquirúrgico,asícomounarevisióndelaliteratura de30casos.

©2016ASOCIACI´ONMEXICANADEENDOSCOPIAGASTROINTESTINALA.C.PublicadoporMasson Doyma M´exico S.A. Estees un art´ıculo Open Access bajo la licencia CC BY-NC-ND(http:// creativecommons.org/licenses/by-nc-nd/4.0/).

Introduction

Endoscopicretrogradecholangiopancreatography(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-volumeof patientsthatpresentwithbiliaryand pan-creatic pathology and are subsequently treated, serious complicationsfromtherapeutic ERCPcan occurin 2.5---8% of cases, with mortality ranging from 0.5% to 1.0%.1,2 Acutepancreatitis, cholangitis,hemorrhage, and perfora-tion,theleadingcomplicationsin 1---7%,1.4%, 1%,and1% 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 subcap-sular hepatic hematoma which evolved with hypovolemic shock and required surgical intervention; we also review thepossiblepathophysiologicalmechanismsunderlyingsuch complication and analyze the sum of the contemporary availableliterature(Table1).

Case

report

A25-year-oldfemalewithahistoryofpregnancyandC sec-tion7monthspriortoadmissionpresented withrecurrent abdominalpainin the upper right quadrant 15 daysprior admission,thepain wasaccompaniedby nausea, vomitit-ing,andjaundice.Laboratoryreportshowedthefollowing: WBC 5.51×1.000/␮L, Hemoglobin 11.5g/dL, platellet count of 310×1.000/␮L, prothrombin time ratio 13.3,

Figure1 ERCPobtainingoneyellowroundbileductstoneof 5mmofdiameter.

internationalnormalizedratio1.16,aspartate aminotrans-ferase 128U/L, alanine aminotransferase 125U/L, Total Bilirubin 3.57mg/dL, DirectBilirubin 2.96mg/dL,alkaline phosphatase928U/L.AnMRCPrevealedintraand extrahe-patic bileductdilationwithadefectin thedistalportion ofthecommonbileduct.ERCPwithbiliarysphincterotomy overa0.035-inchdiameterguidewirewasperformed, can-nulationofthepapillaonafirstattemptwithoutdifficulty followingtheinsertionofa16mmstoneextractionballoon catheter(ShailiEndoscopy®_{)obtainingoneyellowroundbile} duct stone of 5mm of diameter (Fig. 1), control cholan-giography showed no residual defects and the procedure

Subcapsular hepatic hematoma after ERCP 77

Table1 HepaticsubcapsularhematomaafterERCPsummaryofcases.

Reference Age Sex Guidewire Procedure Comorbidity Diagnostic Method Hematoma rupture Onsetof symptoms DelaSerna etal.,1,6,8

71 F Yes Sphyncterotomy+stoneextraction None CT No 48h

Hornetal.1,6,8 _{88 F Yes Biliarybrushing+stent10Fr×7cm Systemichypertension+cholecystectomy NA No 48h}

Cardenasetal1,6,8 _{54 M Yes Sphyncterotomy+stent10Fr×7cm Orthotopiclivertransplant CT No 24h}

Gonzalezetal2 _{30 F NA Spyncterotomy+biliaryballon}

dilation+stent10Fr

None NA No 72h

Oliveiraetal7 _{84 M NA Stoneextraction COPD+pulmonary}

thromboembolism+anticoagulation

CT No 10days

Chietal1,6,8 _{43 F Yes Sphyncterotomy+metalic}

stent+biliaryballoondilation20mm

Cholecystectomy+pancreaticcancer CT Yes 5h

McArthuretal1,6,8 _{71 M Yes Sphyncterotomy+stone}

extraction+stent7Fr

None CT No 12h

Baudetetal1,6 _{69 F Yes Sphyncterotomy+stoneextraction None CT Yes 48h}

DelRosietal9 _{28 F Yes Sphyncterotomy+stone}

extraction+stent10Fr×10cm

Cholecystectomy CT No 48h

Carricaetal4 _{37 F Yes Sphyncterotomy+stoneextraction Cholecystectomy MRI No 72h}

Bartoloetal3 _{66 F NA Sphyncterotomy+stoneextraction None NA No Immediate}

Priegoetal1,6 _{30 F NA Sphyncterotomy None CT No Immediate}

Revueltoetal1,6,8 _{41 NA NA Sphyncterotomy+stoneextraction NA CT No NA}

DelPozoetal1,6 _{76 F Yes Sphyncterotomy+stoneextraction Atrialfibrillation+anticoagulation NA No 6h}

Bhatietal1,6,8 _{51 F Yes Sphyncterotomy+stoneextraction None CT Yes Immediate}

Feietal1,6 _{56 M Yes Sphyncterotomy+stoneextraction None CT No 72h}

Zizzoetal1 _{52 F Yes Sphyncterotomy+stoneextraction None CT No 24h}

Klímováetal6 _{52 M Yes Sphyncterotomy+stoneextraction Chronicpancreatitis CT No 6h}

Perezetal1,6 _{72 F NA Sphyncterotomy+stoneextraction Diabetesmellitus+systemichypertension NA Yes 2h}

Orellanaetal1 _{96 NA NA Ampullarybiopsies+stent Periampullarytumor CT No 4h}

Orellanaetal1,6 _{49 M NA Biliarystentreplacement Testicularcancer+acutepancreatitis CT Yes 2h}

Orellanaetal1,6 _{55 F NA Biliarystentreplacement Gallbladdercancer CT No NA}

Papachristouetal8 _{69 M Yes Billiaryballoon}

dilation+brushing+ampullary

biopsies+stent

Primarysclerosingcholangitis CT NA 48h

DeMayoetal8 _{96 M NA Sphyncterotomy+stent Acutepancreatitis CT No 4h}

Narietal1,6,8 _{15 F NA NA None US No NA}

Ortegaetal1,6,8 _{81 M NA Sphyncterotomy+stoneextraction NA NA NA NA}

Bhandarkaretal8 _{64 F NA NA NA NA NA 10days}

Ertugruletal1,6,8 _{41 M Yes Stent Colangiocarcinoma CT No 48h}

Petitetal1,6,8 _{98 M Yes Sphyncterotomy+stoneextraction Acutemyocardialinfarction+parcial}

gastrectomysec.topepticulcerdisease

CT NA 48h

Poonetal10 _{79 F NA Sphyncterotomy+stent Stroke+congestiveheartfailure CT No Immediate}

78 A. García Tamez et al. Table1 (Continued)

Reference Age Sex Clinicalmanifestacions Treatment Antibiotics Hemoglobin decrease(g/dL)

Death DelaSerna

etal.,1,6,8

71 F RUCpain Conservative Yes NA No

Hornetal.1,6,8 _{88 F RUCpain+anemia Conservative Yes NA No}

Cardenasetal1,6,8 _{54 M Mesogastricabdominalpain Conservative Yes 3.2g/dL No}

Gonzalezetal2 _{30 F RUCpain Surgery Yes NA Yes}

Oliveiraetal7 _{84 M RUCpain Percutaneousdrainage Yes 3.3g/dL Yes}

Chietal1,6,8 _{43 F RUCpain+anemia Embolization Yes NA No}

McArthuretal1,6,8 _{71 M RUCpain Conservative Yes NA No}

Baudetetal1,6 _{69 F RUCpain+fever Embolization+surgery YesCF 7.3g/dL No}

DelRosietal9 _{28 F RUCpain Conservative Yes 7.3g/dL No}

Carricaetal4 _{37 F RUCpain Percutaneousdrainage YesCF 1.3g/dL No}

Bartoloetal3 _{66 F Hypotension+tachycardia Surgery No 10.3g/dL Yes}

Priegoetal1,6 _{30 F RUCpain Surgery Yes NA No}

Revueltoetal1,6,8 _{41 NA Anemia Conservative Yes NA No}

DelPozoetal1,6 _{76 F RUCpain Conservative Yes NA No}

Bhatietal1,6,8 _{51 F RUCpain+hypotension Percutaneousdrainage NA NA No}

Feietal1,6 _{56 M RUCpain Percutaneousdrainage Yes NA No}

Zizzoetal1 _{52 F Epigastricpain Embolization Yes 3.3g/dL No}

Klímováetal6 _{52 M RUCpain Embolization Yes 6g/dL No}

Perezetal1,6 _{72 F RUCpain Surgery NA NA No}

Orellanaetal1 _{96 NA Rightomalgia Conservative Yes NA No}

Orellanaetal1,6 _{49 M RUCpain Embolization NA NA No}

Orellanaetal1,6 _{55 F RUCpain+rightomalgia Conservative NA NA No}

Papachristouetal8 _{69 M RUCpain+rightomalgia+anemia Conservative NA 3.5g/dL NA}

DeMayoetal8 _{96 M Rightomalgia Conservative Yes NA No}

Narietal1,6,8 _{15 F RUCpain+rightomalgia+hypotension Conservative Yes NA No}

Ortegaetal1,6,8 _{81 M RUCpain Percutaneousdrainage Yes NA NA}

Bhandarkaretal8 _{64 F RUCpain+fever+anemia Percutaneousdrainage NA NA NA}

Ertugruletal1,6,8 _{41 M RUCpain+fever Conservative Yes NA No}

Petitetal1,6,8 _{98 M RUCpain+asthenia Percutaneousdrainage NA NA NA}

Poonetal10 _{79 F RUCpain+hypotension Conservative NA 5g/dL No}

Casereport 25 F RUCpain+anemia Surgery Yes 4.2g/dL No

F---female,M---male,COPD---ChronicObstructivePulmonaryDisease,RUC---rightuppercuadrant,CT---computedtomography,US---ultrasound,MRI---magneticresonanceimage,NA ---notavailable,CF---Citrobacterfreundii.

SubcapsularhepatichematomaafterERCP 79

Figure2 Upper endoscopywithduodenoscopewithout evi-denceofbleedingfromsphyncterotomy.

wasfinishedwithoutevident complicationssuchas bleed-ing or injury. 12h post procedure the patient developed rightupperquadrantabdominalpain,hemoglobindropped 4g/dL(Hb7.3g/dL),amylasespikedto162U/Landlipase also showeda rise to 213U/L. There wasno clinical evi-dence of gastrointestinal bleeding. An upper endoscopy wasperformedwithafrontalvideo endoscopeanda duo-denoscopewithoutevidenceofgastrointestinalbleedingor post-sphyncterotomy bleeding (Fig. 2). Three packed red bloodcells(PRBCs)weretransfused,anda12hpost transfu-sionalhemoglobinwasobtainedwhichreported10.3g/dL. Hemoglobin declined to 5.3g/dL 3 days after ERCP. The patient developed grade 4 hypovolemic shock with acute abdomenandpositiveBlumbergsign.Anurgentabdominal ultrasoundrevealedfreefluidintheabdominalcavity.Two morePRBCsweretransfusedandanurgentlaparotomywas performed observing rupture of Glisson’s capsule (Fig. 3) andapproximately3000mlofblood intheperitoneal cav-itywasfound.Abdominalpackingwasperformed andtwo morePRBCsweretransfusedduringsurgery.Thepatientwas admittedtotheIntensiveCareUnit(ICU)whereshehadto have assisted breathingvia endotracheal tube. Therewas noneedforvasoactivesupport.48hlaterasecond laparo-tomywasperformed tounpacktheabdomen.The patient wasextubated6daysafterthefirstlaparotomyandwas dis-chargedfromtheICU.Thepatientevolvedwell,maintaining hemoglobinlevelsat10.9g/dLandwasdischargedfromthe hospital16daysaftertheERCPprocedure.Onemonthlater afollow-upMRIdemonstratedaremanentheterogenic sub-capsular hepatic hematomaof 15.2×10.4×3.6cm in the righthepaticlobe(Fig.4).Currently,thepatientis(3months postERCP)generallywellandreportsslightabdominal dis-comfort,patientsurveillancewillcontinue untilcomplete resolutionofthehematomaisobserved.

Discussion

Bleeding related to an ERCP procedure is usually due to endoscopic sphincterotomy. Bleeding seen endoscopi-cally during or immediately after sphincterotomy is not

Figure3 RuptureofGlisson’scapsuleobservedin laparotomy.

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

sequenceona1.5-TMRImachine.

uncommon,butisgenerallynotconsideredanadverseevent unlessthereissignificantbloodloss,whichismanifestedas evidenthypovolemiaand/orthathasaneedfortransfusion. Whenapplyingclinicalcriteriasuchasmelena, hemateme-sis, a drop greater than 2g/dL in hemoglobin level, or requirementfor secondaryinterventionsuchasendoscopy or blood transfusion,the overall incidence of bleeding is around 0.1---2% even in experienced hands.5 _Subcapsular hepatichematomaisarareandexceptionalevent,ofwhich only30 cases have been reportedsince 2000. The patho-physiologicmechanism underlyingthedevelopmentofthe

80 A.GarcíaTamezetal. hematomais notclearlydefined,howevervariousauthors

agreethatvascularinjuryofsmall-caliberintrahepatic ves-selssecondary to guidewireuse may bethe cause,which mayalsoexplainthepresenceoffreeairanddevelopment ofinfectionsinsomeofthecases.1,6

Patientfactors

Wefoundthatthemedianageofpresentationis59(15---98) years,with58%female and35% maledistribution.Only2 (6.4%)patientshadahistoryofanticoagulationtherapyprior totheprocedure.Almost halfofthepatients(48.3%) pre-sentedclinicalmanifestationsinthefirst24hpost-ERCP.The mostcommonmanifestationwasabdominalpainin87%;in somecasereportsfeverwasmentionedtobeoneofthe pri-marymanifestations,but wefound thatrightomalgiaand clinical manifestations of hypovolemic shock (tachycardia orhypotension)werepresent moreoften9.6%vs16.1%vs 12.9%.

Procedurefactor

In17(54.8%) casestheuse of aguidewire wasreported, butwe cannotexcludeitsuseontheother 14 cases.The literatureonthese14casesdoesnotmentiontheuseofa guidewire.

In most of the cases, 67.7%, diagnosis was performed byCT,but the useof US andMRI wasalso describedin 2 and1cases respectively.In ourcase reportabdominalUS was performed searching for free fluid in the abdominal cavity,becauseofthedevelopmentofan acuteabdomen. In almost half of the patients (45.1%) no invasive treat-mentwasrequired. Percutaneousdrainagewasperformed in 7 (22.5%), surgery in 6 (19.3%), and embolization in 4 (12.9%)patients.Only2casereportsdescribedthepathogen foundinthehematomaculture,bothfoundCitrobacter fre-undii,whichisafacultativeaerobicgram-negativebacilliof theEnterobacteriaceaefamily,commonlyfoundinthe gas-trointestinaltract.In22(70.9%)patientsantibioticswhere used,eitherasaprophylacticmeasureorastreatmentfor infection,8(25.8%)didnotspecifywhethertheyused antibi-otics or not.Only 11 case reports mention a decrease in hemoglobinthat wentbetween1.3g/dLto10.3g/dL,and from those cases, the majority, 63%, required some kind of intervention (embolization, percutaneous drainage or surgery),concludingthathemoglobindecreaseisagood pre-dictorfor requiringintervention,noassociationwasfound betweenhemoglobindropandtheneedofaspecifickindof intervention.3(9.6%)deathswerereported,2patientswho required surgeryand onein whompercutaneous drainage wasperformed.

Becauseofthemortalityratefound intheliteratureit isimportant toconsiderthis asalife-threatening adverse event.Anotherrarecomplicationfollowing ERCPthatcan haveasimilarpresentationasdescribedinthecasereport isinjurytothespleencausingintraperitonealhemorrhage withafewcasesbeingreportedintheliterature.Symptoms oftenincludelocalizedperitonealirritationintheleftupper

quadrant progressingwithtimetogeneralized peritonitis, along withreferred pain to the left shoulder.Changes in vitalsignsincludingtachycardiaandorthostaticchangesin bloodpressurearefrequent.

Conclusions

Subcapsularhepatic hematoma is a rarecondition associ-atedtoERCPthatmustbesuspectedwhenabdominalpain ispresentaftertheprocedure,itmayhaveafatalcourseif itisnotdiagnosedandtreatedearly.Furtherpublicationsof casereportswillhelpestablishriskfactorsandappropriate treatment.

Financing

Nofundingwasreceivedforthiswork.

Conflict

of

interests

Authorsdeclarenoconflictofinterestsforthisarticle.

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