Abdominal Pain Following Endoscopic Retrograde Cholangiopancreatography - Think Beyond Pancreatitis

Abstract

Purpose: A 67 year old man with chronic pancreatitis presented with persistent epigastric pain for 3 months. Previously, he had a pancreatic pseudocyst which was being drained by a percutaneous pigtail catheter (200-300cc daily). Physical examination revealed mild epigastric tenderness but no guarding or rigidity. Routine labs including amylase and lipase were normal. Abdominal CT scan showed collapsed pancreatic pseudocyst and the pigtail catheter in the region of the head of pancreas. This along with high amylase content (>10,000U/L) of the drainage fluid, suggested a pancreatic leak. An ERCP was performed and revealed pancreas divisum with no communication between the ventral and the dorsal/main pancreatic duct. Cannulation of the minor papilla revealed dilated main pancreatic duct and clubbed side branches consistent with chronic pancreatitis but no definite leakage of contrast was seen. Nevertheless, a pancreatic stent was placed in the dorsal pancreatic duct. The procedure was long and difficult due to multiple attempts needed to cannulate the minor papilla. Next day, the patient reported improvement in epigastric pain but complained of mild left upper quadrant (LUQ) discomfort. Soon after, left shoulder pain was reported. On the third day, the patient became hypotensive. The hemoglobin dropped from 11.5 to 5.9 g/dL. A repeat CT scan demonstrated a large splenic hematoma with free fluid in the abdomen suggestive of splenic rupture. An emergency laparotomy showed hemoperitoneum and a ruptured splenic capsule (13 cm × 0.5 cm) with a large hematoma. Splenectomy was performed. The patient had an uneventful postoperative course and was discharged home and remained free of symptoms at his follow up visit. Splenic rupture following an ERCP is extremely rare, described in only a few case reports in the literature. The exact mechanism is unclear. It has been hypothesized that ‘bowing' of the endoscope in the stomach during the procedure especially in the ‘long scope position' exerts pressure and traction on the greater curvature of the stomach, splenocolic or gastrosplenic ligaments, spleen and the short gastric vessels. This can result in splenic capsular tear, splenic laceration or avulsion of the short gastric vessels. Minor papilla interventions are usually performed in the ‘long scope position', thus increasing the risk of splenic injury. Presence of hypotension, drop in hematocrit, Kehr's sign or sudden onset of left upper quadrant pain following an ERCP should alert the physician regarding the possibility of a splenic injury. Timely recognition of this complication can significantly reduce the associated morbidity and mortality.