Right Anterior Sectionectomy for a Subcapsular Hepatic Hematoma Causing Disseminated Intravascular Coagulation Following an Endoscopic Retrograde Cholangiopancreatography

Abstract

A 29-year-old female diagnosed with an acute cholecystitis and choledocholithiasis in a different medical center, was treated by an ERCP with sphincterotomy, being discharged 4 days later due to pain in the right hypochondrium radiated to the right cervical region and the diagnosis of hospital acquired pneumonia. 11 days after the initial procedure she came to our Emergency Department due to persistent pain in the right hypochondrium. She was hemodynamically stable with 99/62 blood pressure, heart rate of 70 bpm and a temperature of 36 C. The computed tomography scan on admission showed a liver dependent heterogeneous collection, predominantly hypodense with hyperdense material that formed a liquid - liquid level, measuring 157 x 188 x 96 mm with a volume of 1,481 cc that created a mass effect on liver parenchyma, compatible with subcapsular hematoma. A conservative management was proposed but in the fourth day of inpatient stay the hemoglobin levels dropped from 8.6 g/dL to 8.0 g/dL and the platelets dropped from 397 K/mL to 44.4 K/mL in the daily controls. A diagnosis of Disseminated Intravascular Coagulation was made and an urgent exploratory laparotomy was proposed. A big subcapsular hematoma involving segments V – VIII with 1,500 cc of clotted material was found. Drainage and rinsing of the hematoma were made and a right anterior sectionectomy was performed. On postoperative, patient showed no signs of complications. A control CT scan showed a small subphrenic collection with a well-placed drain. The patient was discharged after 7 days with no further complications.