S1541 An Unexpected Complication of Endoscopic Retrograde Cholangiopancreatography With a Unique Treatment Approach

Abstract

INTRODUCTION: ERCP is an invasive technique in which an endoscope is passed from the mouth, down the esophagus, through the stomach, and to the hepato-pancreatic ampulla. Complications from an ERCP range from about 6-10% and carries an overall mortality of 0.5% to 1%. The most common complications after an ERCP include acute pancreatitis, esophageal/duodenal perforation, and infection. One rare and life threatening complication, having less than 30 documented cases, is splenic injury. CASE DESCRIPTION/METHODS: A 52 year old male with no past medical history presents to the emergency department abdominal pain and a fever of 101. After evaluation, the patient is diagnosed with choledocholithiasis and plans are made to proceed with ERCP and cholecystectomy. The following day, ERCP with common bile duct stenting was performed. The procedure was complicated by a difficult to cannulate hepato-pancreatic ampulla, requiring a prolonged procedure time. After completion of the ERCP, the patient was repositioned for laparoscopic cholecystectomy. Upon entry, significant hemoperitoneum was encountered with active hemorrhaging noted at the anterior and superior splenic poles. Once hemorrhaging was controlled, the gallbladder was removed. The patient received one unit of packed red blood cells and was transferred to the ICU. Overnight, the patient became hypotensive and developed increased bloody output from closed suction post-operative drains, requiring the patient to receive 5 units of packed red blood cells and multiple liters of IV fluids. Patent was taken emergently to interventional radiology for splenic artery embolization. Embolization was successfully completed using endovascular coiling with no complications. After embolization, the rest of the patient’s hospital stay was uneventful. DISCUSSION: The specific mechanism of post-ERCP splenic injury remains unknown. One potential explanation that fits with the case presented involves the bowing and torsion of the endoscope while attempting to cannulate a difficult hepato-pancreatic ampulla. During this procedure, torsion on the greater curvature of the stomach will translate to direct forces on the surrounding organs, including the splenic capsule and vasculature. As demonstrated in the case, a high index of suspicion is vital to properly manage such a complication. With the always improving capabilities of interventional radiological procedures, splenic artery embolization can potentially prevent splenectomy as a result of post-ERCP splenic laceration.Figure 1.: Coronal slice from CT abdomen and pelvis demonstrating large splenic size after hemorrhage and splenic artery embolization.Figure 2.: Anterior/posterior slice from CT abdomen and pelvis demonstrating large splenic size after hemorrhage and splenic artery embolization.