Subcapsular Hematoma: An Unusual Complication of ERCP

Abstract

Endoscopic retrograde cholangiopancreatography (ERCP) developed in 1968 is a minimally invasive procedure for diagnosis and treatment of biliary and pancreatic disease. Complications include cholangitis, perforation, bleeding and pancreatitis. They occur in 2.5-8% of cases with mortality rates ranging 0.5-1.0%. Hepatic hematoma post ERCP is an exceedingly rare complication with only a limited number of cases described in the literature. Presented is a case of a subcapsular hematoma following ERCP. A 39-year-old female presented with acute, diffuse abdominal pain associated with non-bloody, non-bilious vomiting one day after ERCP for elevated liver tests. ERCP showed a 3cm stricture in the mid common bile duct (CBD) with proximal dilation of the biliary tree and CBD to 14mm. A 7 Fr x 7mm CBD stent was placed. Sphincterotomy was not performed. On admission, vital signs were within normal limits. Labs were significant for total bilirubin 2.4 mg/dL, alkaline phosphatase 215 U/L, AST 208 U/L, ALT 496 U/L, lipase 2730 U/L, Hgb 12.9 g/dL. CT abdomen showed a 5.8 x 5.6 x 18cm collection in relation to the right lobe of the liver concerning for subcapsular hematoma. Due to persistent abdominal pain, repeat CT was performed showing expansion now measuring 12 x 6.8 x 21cm. A right hepatic arteriogram was performed by IR revealing a pseudoaneurysm arising from a peripheral branch of the right hepatic artery that was embolized. She had ultrasound-guided drainage of the subcapsular hematoma with 500cc of blood drained. She completed 5 days of ceftriaxone and metronidazole for prophylaxis and was discharged on hospital day 8. Subcapsular hematoma is a rare complication that requires early identification and intervention. Presentation with severe abdominal pain and/or hypotension with associated nausea and/or vomiting should raise concern for a subcapsular hematoma. Symptoms often occur within the first 24 hours but can present as late as 2 weeks post-ERCP. A decreasing hemoglobin or hematocrit is the only laboratory finding that may raise suspicion in certain cases. Hematomas can occur as a result of incidental rupture of small caliber intrahepatic vessels due to advancement of the ERCP guide wire. Post ERCP diagnostic imaging consists of abdominal ultrasound, CT or MRI. In our case, due to an active bleeding vessel, embolization was warranted, but in a majority of cases conservative measures were the treatment of choice.1947_A Figure 1. CT Abdomen performed on admission showing a 5.8 x 5.6 x 18cm collection.1947_B Figure 2. CT Abdomen performed 12 hours after admission showing a 12 x 6.8 x 21cm collection.