INTRODUCTION: Splenic injury following endoscopy occurs very rarely but can be potentially fatal. There have been only twenty cases reported of ERCP-related splenic trauma since 1989. We present a rare case of post-ERCP splenic laceration and decapsulation. CASE DESCRIPTION/METHODS: 86-year-old man presented with a 4-day history of worsening painless jaundice. Medical history included advanced dementia, coronary artery disease, and hypertension. CT scan of the abdomen/pelvis with IV contrast showed intrahepatic biliary duct dilation (left greater than right) with concern for hilar cholangiocarcinoma. On presentation, the patient was afebrile and hemodynamically stable. Physical examination showed scleral icterus and jaundice. Labs: bilirubin 25.2 mg/dL, ALP 1,361 U/L, ALT 244 U/L, and AST 475 U/L. An ERCP was completed. A J-shaped stomach was observed but the duodenum was intubated without difficulty. Cholangiogram showed complete obstruction at the level of the hilum consistent with Bismuth-Corlette IIIb. Biliary sphincterotomy and balloon dilation, to 6 mm, were performed at the level of the hilum and left main. Bilateral plastic stents were successfully placed in the left and right main duct. Six hours post-procedure, the patient became lethargic and unresponsive. Vital signs: Systolic BP 60 mmHg, HR 40. Abdomen had decreased bowel sounds and was diffusely tender; NG tube lavage showed bile; stool was brown. Labs: Hgb 6.3 g/dL (baseline 10.3 g/L), lactic acid 5.9 mmol/L, WBC 11.4 K/µL. CT scan of the abdomen/pelvis showed active hemorrhage along the posteromedial aspect of the spleen with adjacent blood (Figure 1). Due to many comorbidities, he was a high risk for splenectomy. He underwent embolization of the proximal splenic artery (Figures 2 and 3). An avascular portion of the spleen consistent with splenic laceration and decapsulation was noted during angiography. Despite successful embolization, the patient developed multi-system organ failure and was placed on hospice care. DISCUSSION: Despite an uneventful ERCP, the patient suffered a splenic laceration and decapsulation. Possible mechanisms of injury include excess traction on the gastrosplenic ligament, direct trauma, prolonged procedure time, long scope position, and adhesions. A high index of suspicion for splenic injury is required in any patient who has severe abdominal pain, anemia, or hemorrhagic shock after ERCP.Figure 1.: Cross-sectional view of abdominal CT abdomen/pelvis showing splenic hemorrhage with hemoperitoneum.Figure 2.: Angiogram of splenic artery.Figure 3.: Status post proximal splenic artery embolization.