Subcapsular Collection Research Articles

EP72 - Spontaneous Hepatic subcapsular Biloma Secondary to Choledocholithiasis with concurrent calculous cholecystitis

Abstract Introduction The term "Biloma," introduced in 1979 by Gould and Patel, denotes an encapsulated extrahepatic bile collection primarily caused by iatrogenic or traumatic injuries1. Spontaneous Biloma, a rare non-traumatic occurrence, involves the spontaneous perforation of extrahepatic or intrahepatic bile ducts. In our case report, the spontaneous Biloma developed because of an abrupt increase in bile duct pressure secondary to biliary obstruction because of choledocholithiasis 2. Case Report We present an 85-year-old male with calculous cholecystitis and concurrent choledocholithiasis, leading to acute severe cholangitis. There was no history of surgery, instrumentation, or trauma. He exhibited hemodynamic instability and acute renal failure. Diagnostic tests revealed raised inflammatory markers and deranged liver and kidney functions. CT scans unveiled a large subcapsular liver collection compressing the parenchyma (Figure a &b), alongside dilated intrahepatic biliary radicles, common bile duct, and choledocholithiasis. Treatment Nowadays, treatment for spontaneous Biloma is nonsurgical. Urgent endoscopic drainage and percutaneous transhepatic cholangiogram (PTC) – (Figure c) were performed, followed by ERCP, sphincterotomy, and stone removal (Figure d) once the patient stabilized3. Subsequent CT scans indicated resolution of the subcapsular collection (Figure e). During recovery, the patient experienced a small pulmonary embolism, managed conservatively. Conclusion This case underscores the rare occurrence of spontaneous hepatic subcapsular Biloma associated with choledocholithiasis in an elderly patient. Timely intervention with endoscopic and radiological procedures proved effective, leading to resolution of the Biloma and successful management of causative pathology.

Rupture of intrahepatic bile duct after ERCP for common bile duct stone: A case report of rare complications.

Complications after endoscopic retrograde cholangiopancreatography (ERCP) are diverse and usually treated with nonoperative management or percutaneous drainage; however, there are still some rare, life-threatening complications. This is an extremely rare case of biliary peritonitis caused by rupture of the intrahepatic bile duct after ERCP. A 63-year-old male underwent ERCP for common bile duct stones. On the second day after the procedure, the patient developed sepsis and abdominal distention. Contrast-enhanced computed tomography revealed a subcapsular hepatic fluid collection attached to the bile duct of segment VII. Sepsis resulted in liver parenchyma rupture and intrahepatic bile duct injury after ERCP. Intraoperative cholangiography revealed a connection between a hole in the liver parenchymal surface and the intrahepatic bile duct. Surgeons performed the cholecystectomy, inserted a T-tube into the common bile duct stones, sutured the defect, and put 2 drainage tubes around the lesion. Postoperative recovery was uneventful, and the patient was discharged on the 17th postoperative day. Intrahepatic bile duct perforation after ERCP can lead to rupture of the liver parenchyma, biloma, or abdominal peritonitis. Multidisciplinary management is necessary to achieve favorable outcomes.

Unusual Presentation of Hepatocellular Carcinoma with Peritoneal Carcinomatosis: Importance of Abdominal Distension as a Clinical Indicator

Hepatocellular carcinoma (HCC) is a common malignancy of the liver. It is frequently diagnosed in the male gender with a racial predilection towards Asian and African populations. In addition to distant metastasis, large tumors can result in direct extrahepatic metastasis to the peritoneum and diaphragm through rupture of exophytic tumor hepatocellular carcinoma in peritoneal cavity. We report a case of a 55-year-old male having hepatocellular carcinoma secondary to hepatitis C with peritoneal metastasis. The CT abdomen with contrast triphasic study was suggestive of alarming features of chronic liver disease with multicentric hepatoma formation predominantly in segment VIII with the localized subcapsular collection. Additionally, an extensive omental thickening and nodularity were also seen in subhepatic space. Multiple nodules were seen in right cardiophrenic angle, right lower abdomen, and rectovesical pouch. In contrast to conventional chemotherapy with sorafenib, cytoreduction surgery with hyperthermic intraperitoneal chemotherapy has been shown to dramatically improve survival in patients

#5095 THE CURIOUS CASE OF GAS IN THE GRAFT KIDNEY

Abstract Background and Aims Emphysematous pyelonephritis (EPN) denotes a severe infection of renal parenchyma resulting in necrosis and gas accumulation in the renal and perirenal tissue. Risk factors for urinary tract infections in renal transplant recipients include advanced age, female gender, reflux nephropathy prior to transplantation, diabetes mellitus, deceased donor kidney, kidney–pancreas transplant, retransplantation, antibody induction for immunosuppression, urinary bladder catheterisation, history of allograft rejection with subsequent escalation of immunosuppressive therapy and use of ureteral stents. There are no definite guidelines for management of EPN in renal allografts. If unstable and deteriorating, graft nephrectomy should be undertaken as soon as possible. Any delay in surgical intervention, be it percutaneous drainage or nephrectomy may result in death. Method A 25-year old male, diagnosed with IgA Nephropathy (IgAN) received a living donor renal transplant from his mother in 2013 after a dialysis vintage of 3 years. He received Basiliximab induction followed by maintenance immunosuppression with Tacrolimus, Mycophenolate mofetil and Prednisolone. He had no history of UTI in the immediate post-transplant period. His blood glucose levels were within normal limits and he had not had any urological intervention. In 2019, patient was diagnosed with IgAN recurrence as a cause of chronic renal allograft injury. His Creatinine at last follow up in July 2022 was 4.1 mg/dL. He presented in September 2022 with fever, chills, vomiting, pain in the right iliac fossa and inability to extend his right leg. At presentation, his BP was 86/60mmHg, with pyrexia and tachycardia. Ultrasonography revealed an ill-defined collection superomedial to the graft kidney with doubtful posterior extension and air foci. Non-contrast CT study revealed a large subcapsular collection, extending posteriorly into the right iliac fossa involving the right psoas major and inferiorly into the pelvis, with air foci and no evidence of any urinary tract obstruction suggestive of Acute Emphysematous pyelonephritis with ruptured abscess. He was started on broad-spectrum iv antibiotics- Meropenem and Levofloxacin. Immunosuppression was reduced. Laboratory investigations revealed total leucocyte count of 37,000 cells/mm3, Creatinine of 11 mg/dL, urine routine microscopy revealed field full of pus cells. Blood and urine cultures grew ESBL Escherichia coli. He was taken up for urgent urological intervention in the form of percutaneous drain insertion. Frank pus was aspirated and 200mL drained instantaneously, cultures of which demonstrated the same organism. Within 24 hours of pus drainage, patient became afebrile and had pain relief. He was given 3 weeks of culture-appropriate iv antibiotics, to continue another 3 weeks of oral Carbapenem. However, his graft dysfunction persisted, with no recovery and he became dialysis-dependent. Discussion EPN of the renal allograft is a rare occurrence. A study of EPN in renal transplant recipients by Alexander et al from 2012 revealed 18 out of 22 patients were diabetics, 9 necessitated graft nephrectomy and 7 required percutaneous drainage in addition to antibiotics4. Till date, up to 30 cases of graft EPN have been reported in English literature. The striking feature is that more than 90% of these cases were diabetic. Conclusion The complete pathogenesis of renal allograft EPN, especially in patients with no apparent traditionally described risk factors remains yet to be understood. A high degree of suspicion and early intervention may help to save the allograft.

A Case Report on Perinephric Abscess Caused by Extended-Spectrum Beta-Lactamase-Producing Klebsiella pneumoniae

Perinephric abscess is a rare life-threatening condition. It can complicate a urologic infection or occur secondary to hematogenous seeding. We report a case of a 49-year-old diabetic female who came to the outpatient department with complaints of right-sided abdominal pain for 2 days. It was associated with fever, headache, vomiting, and generalized weakness. Non-contrast computerized Tomography (NCCT) showed a subcapsular collection measuring 6.1× 5.7 × 4.4 cm noted adjacent to the lateral aspect of the right kidney. Following percutaneous nephrostomy, thick pus was drained from the abscess and sent for culture and sensitivity in the microbiology laboratory. Culture grew extended-spectrum beta-lactamase-producing (ESBL) Klebsiella pneumoniae which was sensitive to Carbapenems, Piperacillin Tazobactam, Fluoroquinolones, Netilmicin, Amikacin, and Tetracycline. The patient improved on treatment with the appropriate antibiotics. Perinephric abscesses should be considered as a differential diagnosis of fever with abdominal pain or flank pain since its non-specific nature can delay the diagnosis. Underlying diabetes mellitus (DM), urinary tract abnormalities, and immunodeficiency should be considered in a patient with a perinephric abscess. Ultrasonography (USG) and Computerized Tomography with contrast enhancement are crucial for diagnosis. The drainage of the abscess, either percutaneous or open, should be done. Klebsiella pneumoniae is a frequent cause of perinephric abscesses and mostly follows a complicated urinary tract infection. With high mortality rates, early diagnosis, and effective treatment of perirenal abscesses are required to improve the prognosis of patients.

SUCCESSFUL ANAESTHETIC MANAGEMENT OF A CASE OF OPEN NEPHRECTOMY FOR GRADE 5 RENAL INJURY

Blunt trauma to the abdomen can cause damage to vital organs like spleen, liver, kidney and intestines and is associated with high morbidity. Hereby we are presenting a case of Grade 5 Renal Injury(shattered kidney) following blunt injury abdomen. A 21 year old male presented to our Emergency Room with history of RTA. He revealed history of severe abdominal pain. He presented with severe tachycardia (HR−140⁄minute),blood pressure and saturation were normal and GCS was 15⁄15. His CECT abdomen revealed shattered left kidney with subcapsular and perinephric collection with renal vascular injury. His hemoglobin was found to be 5.7g/dl, rest of the blood investigations were within normal limits. He was shifted to OT immediately and was proceeded with open nephrectomy. Post induction he devoloped severe hypotension and was started on iv crystalloids and colloids and minimal Nor adrenaline support. Intraoperatively 4 units of PRBC and 3 units of FFP were transfused. Around 1 litre of blood, bladder clots and a concealed hematoma in messentry were evacuated. Post transfusion ABG revealed metabolic acidosis. He was shifted to ICU with the ET Tube. He made an uneventful recovery in ICU and was extubated.Physiologically, hemodynamic compensatory mechanisms maintain vital organ perfusion till about 30% TBV loss, beyond which there is a risk of critical hypoperfusion. Massive blood loss is best managed by following the massive transfusion protocol (MTP).

S2858 Post-ERCP Subcapsular Hepatic Hematoma

Introduction: Endoscopic retrograde cholangiopancreatography (ERCP) is both a diagnostic and therapeutic procedure used for management of biliary pathology. Rates of even the most common complications, including biliary perforation and pancreatitis, are low, however other complications can be life-threatening and must be kept in mind when evaluating a patient post-ERCP. Here, we describe a case of post-ERCP subcapsular hepatic hematoma (SHH). Case Description/Methods: A 39-year-old man with a history of hypertension, type II diabetes mellitus and alcohol use disorder complicated by chronic pancreatitis with multiple episodes of common bile duct (CBD) stricture status post multiple ERCPs presents with epigastric pain and right upper quadrant pain. He was admitted two weeks prior for epigastric pain, where he was found to have CBD stricture, and underwent ERCP with stent placement. Pain did not completely resolve after his last hospitalization and escalated to a 10/10. On arrival, he was afebrile with stable vitals. Physical exam demonstrated epigastric tenderness to palpation with voluntary guarding, but a soft abdomen without rebound tenderness. Labs significant for WBC count of 10.8 x 10^9/L, alkaline phosphatase of 117 U/L, and hemoglobin 11.7 g/dL. Abdominal ultrasound showed a 7.3 x 3.9 cm area of mixed echogenicity in the right liver lobe. Triple phase CT of the abdomen and pelvis showed a 9 x 6.5 x 2.5 cm heterogeneous subcapsular liver collection. He was given Zosyn, and WBCs downtrended. On day 3, liver function tests (LFTs) rose: aspartate aminotransferase was 397 U/L, alanine aminotransferase was 206 U/L, alkaline phosphatase was 571 U/L, and total bilirubin was 5.0 mg/dL. Repeat CT showed expected hematoma resolution with correct biliary stent placement. Antibiotics were re-started. LFTs and symptoms improved. He was discharged on a 14-day course of Levofloxacin and Metronidazole. (Figure) Discussion: SHH is a rare but known complication of ERCP. Hematomas can expand, resulting in significant anemia and LFT elevation, or become infected with resultant sepsis. Patients with SHH must be carefully monitored in the post-ERCP setting. This patient exhibited an elevated WBC count with delayed elevation in LFTs, concerning for potential infection of the hematoma, yet without overt signs of infection, including lack of fever. He was managed with antibiotics without hematoma drainage, demonstrating the efficacy of conservative management for such a potentially deadly complication of ERCP.Figure 1.: Triple phase computed tomography scan of the abdomen and pelvis demonstrating a right-sided subcapsular hematoma in segment 6 of the liver in the coronal (a) and transverse (b) planes (arrow).

S2832 First Trimester Subcapsular Hepatic Hematoma Following Endoscopic Retrograde Cholangiopancreatography

Introduction: Endoscopic retrograde cholangiopancreatography (ERCP) is commonly utilized to treat pancreaticobiliary diseases and is considered safe in pregnancy. We describe a case of ERCP indicated for choledocholithiasis in a newly pregnant patient which resulted in a very rare complication related to guide wire trauma. Case Description/Methods: A 24-year-old female presented to the emergency department with right upper quadrant pain, fever, leukocytosis, and obstructive jaundice. Bloodwork revealed she was 8 weeks pregnant. Imaging studies showed acute cholecystitis and choledocholithiasis with a dilated common bile duct of 1.2 cm. Therapeutic ERCP was performed with minimal use of fluoroscopy to reduce fetal exposure. Double wire technique was utilized and the bile duct was successfully cannulated with a 0.025 mm angled-tipped hydrophilic wire. Sphincterotomy was performed, followed by sphincteroplasty. The bile duct was swept with a 12 mm balloon but only one stone was extracted. To avoid further fetal fluoroscopy exposure, double plastic stents were placed into the common bile duct and a single pigtail plastic stent was placed into the pancreatic duct. The following day, she became hemodynamically unstable. Labs suggested an improved cholestatic pattern and improved leukocytosis post ERCP decompression. Due to worsening hepatocellular injury and hemodynamic instability, a computed tomography angiogram was performed. A 3.9 cm subcapsular hepatic hematoma with capsular retraction and parenchymal distortion of the superior right hepatic lobe was found. Interventional radiology catheter embolization was attempted. Aggressive conservative management with blood transfusions and close monitoring successfully stabilized the patient. The patient ultimately had a spontaneous abortion and returned for an outpatient ERCP with biliary stent removal and stone extraction. Discussion: Although a very rare complication, this case does highlight the possibility of angled-tipped hydrophilic guide wire hepatic trauma and clinically significant bleeding. When strongly indicated, ERCP should be performed in people who are pregnant, but exposure to fluoroscopy should be minimized. Similar cases hypothesize that liver injury is attributable to traumatic damage to the intrahepatic biliary tree and hepatic parenchyma by the ERCP guide wire.Figure 1.: Computed tomography of the abdomen revealed a hypodense subcapsular collection on the right side of the liver. The bleed continues inferiorly and medially. A plastic pancreatic stent and a plastic biliary stent are also visible.

Spontaneous subcapsular renal hematoma in a patient with pauci-immune glomerulonephritis

Spontaneous subcapsular renal hematoma is a rare occurrence. We report a 42-year-old male with rapidly progressive glomerulonephritis who developed sudden-onset right flank pain. Imaging showed a large subcapsular collection in the right kidney, for which urgent nephrectomy was done due to hemodynamic instability. Histopathology from the nephrectomy specimen was suggestive of pauci-immune glomerulonephritis with crescents. The patient received pulse methylprednisolone followed by injectable cyclophosphamide.

Page Kidney: A Secondary Cause of Hypertension

Page kidney is a rare cause of secondary hypertension in adults that occurs due to extrinsic compression of the kidney due to a subcapsular collection, such as a hematoma or urinoma. Usually these subcapsular formations are a result of trauma to the kidney such as from a biopsy or motor vehicle accident. Here we present a case of a 61-year old African American male who presented to the hospital with worsening shortness of breath for 2 days, a blood pressure of 203/156, and a BNP of 206. He was admitted and treatment was begun for diastolic congestive heart failure and hypertensive emergency. Clinically, he was improving but his systolic blood pressure continued to be in the 150’s despite multiple blood pressure medications. Due to this difficulty in controlling blood pressure and a negative renal ultrasound, an abdominal CT scan with contrast was ordered and revealed a subcapsular fluid collection indenting the lateral margin of the left kidney measuring approximately 7.1 x 5.4 x 2.3 cm that was suggestive of a Page kidney per radiology. Upon further history taking it was found that the patient has had received extracorporeal shock wave lithotripsy for nephrolithiasis in past several months which is a known risk factor for subcapsular hematoma formation. Ultimately it was determined that this subcapsular hematoma was resolving on its own and no intervention was needed other than follow-up as an outpatient. We feel this case is noteworthy for not only being a presentation of a Page kidney, but also demonstrates the importance of considering a secondary cause to hypertension in patients with difficult to control hypertension.

Unusual Sites of Necrotic Collections in Acute Necrotizing Pancreatitis: Association with Parenchymal Necrosis and Clinical Outcomes.

The presence of necrotic collection in acute necrotizing pancreatitis (ANP) at intra-abdominal sites other than theretroperitoneum has not been systematically studied. To investigate unusual sites of necrotic collections at computed tomography (CT) and to evaluate association with pancreatic necrosis and clinical outcomes. This retrospective study comprised of consecutive patients with ANP evaluated between January 2018 and March 2019. Based on CT findings, patients were divided into two groups: collections at unusual sites (small bowel mesentery, mesocolon, omentum, subcapsular collections along liver and spleen, pelvis, anterior abdominal wall, and inguinoscrotal regions) and collections at usual retroperitoneal locations (lesser sac, gastrosplenic location, anterior and posterior pararenal spaces, and paracolic gutters). The differences in CT findings and clinical outcomes (need for drainage, length of hospitalization, intensive care unit admission, surgery, and death) between the two groups were evaluated. A total of 75 patients with ANP were evaluated. There were 25 (33.3%) patients with collections in unusual locations. These included mesentery (n = 17), splenic subcapsular location (n = 7), omentum (n = 6), hepatic subcapsular location (n = 4), anterior abdominal wall (n = 3), pelvis (n = 2), and inguinoscrotal location (n = 1). Compared to patients with collections at usual locations (n = 50), there were no differences in the CT findings except complete parenchymal necrosis (32% vs. 0%, P = .001). There were no statistically significant differences in the clinical outcomes between the two groups. Mesenteric collections are frequent in ANP. The other non-retroperitonealsites are infrequently involved. There is no association between unusual sites of collection and clinical outcomes.

Totally laparoscopic simultaneous resection of colorectal cancer and synchronous liver metastases

Background: While laparoscopic resection of the colorectal carcinoma (CRC) and laparoscopic hepatectomy have rapidly evolved in the past years, there is a lack of reported experiences in totally laparoscopic [TL] simultaneous resection [SR] in CRC with synchronous liver metastasis (LM). Methods: A retrospective analysis of a single-center experience was performed. ASA=4 or ECOG>2 patients, symptomatic primary tumors and low rectal tumors were excluded. 4 points in the Iwate score were not exceeded. Results: A total of 12 TL-SR were carried out from August 2009 to December 2018. 6 patients were female and median age was 61,5±12,04 years. 8 tumors were located in the colon and 4 in the rectum. 14 LM were diagnosed preoperatively (11 unique, 1 triple); however, 4 new LM were found with intraoperative-US. Liver surgery consisted in: 1 case of left lateral sectionectomy and 11 cases of non-anatomical resections. Radiofrequency ablation was associated in 1 case. Mean operative time was 320±25 minutes. Surgery started with the liver resection in 10 cases. 3 cases (25%) presented major complications: one biliary leak with pseudoaneurysm of the liver artery in an hemophiliac patient, one subcapsular liver collection and one anastomotic leak in a rectal tumor that received neoadjuvant chemotherapy. Median hospital stay was 6,5 days (4-34). After a median of follow-up: 19 months (IQR 12-33), tumor progression was observed in 4 cases (33.3%): 3 in the liver, all of which received rescue surgery with curative intention and 1 generalized who received palliative chemotherapy. Median time to recurrence 8,5 months (r1-22). An hemophiliac patient died at 5th month due to a stroke (disease free). Conclusions: Totally laparoscopic simultaneous resection of stage IV CRC with LM is technically feasible in selected patients without a significant increase of morbimortality and no impairment of oncological outcomes although more experience and longer follow-up are needed.

1699 Stent Gone Rogue: Endoscopic Removal of a 3-Year-Old Embeded Cystgastrostomy Stent

INTRODUCTION: We present a case of endoscopic removal of a delayed SEMS migration into the retroperitoneum, resulting in a perisplenic abscess and embedding of the SEMS into the gastric and retroperitoneal wall. CASE DESCRIPTION/METHODS: A 60-year-old man with idiopathic acute necrotizing pancreatitis complicated by walled-off pancreatic necrosis (WOPN) status post EUS-guided cystgastrostomy 3 years prior, presented with 3 weeks of worsening chronic abdominal pain and fever. Previous cystogastrostomy was performed with a through the scope 18 mm × 60 mm fully covered self-expandable esophageal metal stent (SEMS). Plan was to have SEMS removed after WOPN resolution; however, patient was lost to follow up. Abdominal CT scan revealed fluid collection in pancreatic tail measuring 4.8 × 1.9 cm and cyst-gastrostomy stent in place, splenomegaly measuring 15.5 cm with a perisplenic subcapsular collection along the lateral and superior splenic margin measuring 13.3 × 1.9 cm, thin fluid tract/collection extending from the pancreatic tail with more superior extension to questionably communicate with perisplenic collection. The 3-year-old SEMS was attempted to remove with a new through the scope fully covered 18 mm × 60 mm esophageal SEMS (Taewoong medical) but failed. Following, a new 20 mm lumen-apposing metal stent (LAMS) (Axios, Boston Scientific) stent was deployed within the embedded 3-year-old SEMS and it was secured to the embedded stent with standard clipping (Cook Medical), and CT abdomen 3 weeks after discharge noted improvement of perisplenic fluid collections. Follow up EGD/EUS allowed successful removal of 6F drainage catheter and inner Axios stent with rat tooth. After prolonged efforts, utilizing snare, biopsy, and piecemeal extraction, the embedded 3-year-old SEMS with wire struts and lattice fixed into the gastric wall and retroperitoneum was removed with no fragment remaining that was confirmed multiple times on endoscopy and fluoroscopy. Finally, Patient remained in good health without recurrence of symptoms at 6-months follow up in the outpatient clinics. DISCUSSION: This is the first case report of successful endoscopic removal of a 3-year-old embedded cystgastrostomy stent. Watch the video: http://bit.ly/2Lvc78C.

Large Hepatic Subcapsular Hematoma Secondary to Double-J Stent Placement

Introduction and Background: Urinary diversion with the endoscopic Double-J stent is a frequent procedure; complications can include irritation, suprapubic or flank pain, vesicoureteral reflux, hematuria, or urinary infection. We report a case of hepatic subcapsular hematoma secondary to Double-J stent placement. Case Presentation: A 28-year-old woman presented with a history of Sjögren's disease, nephrocalcinosis, and chronic kidney disease (CKD). The patient underwent multiple percutaneous and endoscopic procedures during the previous 2 years: right kidney: extracorporeal shock wave lithotripsy (SWL) × 4, ureteroscopic lithotripsy × 2, percutaneous nephrolithotomy (PCNL), and retrograde intrarenal surgery; left kidney: SWL × 2, ureteroscopic lithotripsy × 5, and PCNL. Ultrasound imaging showed severe dilation in the right kidney and moderate dilation in the left kidney. CT scanning without contrast revealed a right pyelourethral dilation caused by a 13 mm ureteral lithiasis; also, cortical atrophy was observed. Urosepsis with exacerbated CKD was diagnosed and bilateral 7F Double-J stents were placed on both sides under general anesthesia. On postoperative day (POD) 8, the patient presented with pain in the right hemithorax and dullness to percussion. CT scans showed a heterogeneous hepatic subcapsular collection, of 15 × 7 × 23 cm, of hematic aspect, displacing vascular structures, and no active bleeding. Treatment was expectant and symptomatic. On POD 16, a new CT scan ruled out progression of the hematoma. The patient was finally discharged on POD 19. Four months later, bilateral semirigid ureteroscopy showed a right ureteral lithiasis of 8 × 7 mm, which was fragmented with a holmium laser. Nineteen months after the first episode, the patient is asymptomatic, with no residual lithiasis or hepatic hematoma. Conclusion: This case shows a very rare complication of Double-J stent placement that could be managed by conservative treatment.

Resolución de colección biliar gigante por fistulización espontánea al colon

The treatment of bile collections is divided into: expectant attitude with radiological monitoring of the size and characteristics of the collection, percutaneous drainage guided by imaging tests (US/CT), endoscopic drainage depending on location and accessibility and surgical treatment. The clinical case of a man undergoing a scheduled hepatectomy was observerd, who presented a large asymptomatic subcapsular collection suggestive of bilioma, with progressive increase in size, spontaneously presenting a decrease until its resolution by fistulization to the hepatic angle of the colon confirmed by Radiological findings. The spontaneously formation of biliary fistulas to the colon is due to the extrinsic pressure of the collection on the intestinal wall with necrosis of the contact zone, being its presentation and radiological documentation exceptional.

A Rare Cause of Renal Atrophy: Subcapsular Collection Presented as a Huge Perirenal Complex Cyst

A Rare Cause of Renal Atrophy: Subcapsular Collection Presented as a Huge Perirenal Complex Cyst

Splenic Rupture: A Rare Complication of Extracorporeal Shock Wave Lithotripsy.

A 41-year-old man presented at the emergency department with complaints of intolerable pain in the left upper quadrant. He had undergone extracorporeal shock wave lithotripsy (ESWL) eight hours prior as treatment for a left-sided kidney stone in the upper pole. Ultrasound demonstrated a large subcapsular hyperechoic collection in the spleen ( Figure 1 ). A computerized tomography (CT) scan confirmed a laceration of the lower pole of the spleen with a subcapsular hematoma and a discrete amount of surrounding free fluid. Adjacent to the splenic laceration, a smaller subcapsular hematoma was also present in the left kidney ( Figure 2 ). In the meantime, a fragmented stone in the proximal left ureter was visualized (1400 HU). The therapy was conservative with hemodynamic follow-up in the intensive care unit with normal patient recovery

A rare case mimicking positron emission tomography/computed tomography mismatch: Hepatic subcapsular hematoma.

Subcapsular collections of bile, air or blood in the liver have been described following transhepatic procedures due to the leakage of bile and blood from the percutaneous puncture at the surface of the liver. Herein we presented the subcapsular collection led to a mismatch between functional and anatomical boundaries of the liver.

Page kidney after botulinum toxin injection during chiropractic care

Page kidney refers to the phenomenon of hypertension secondary to long-standing compression of renal parenchyma caused by renal subcapsular collection. The most common cause of renal subcapsular collection is a hematoma which usually occurs after a history of blunt trauma. A 42-year-old female patient who received botulinum toxin injection in her back during chiropractic care was admitted to the emergency room with sudden bilateral flank pain and hypertension. The computed tomography (CT) images demonstrated the presence of bilateral subcapsular renal hematoma. The patient was treated conservatively and recovered well. The follow up CT images showed markedly resolved bilateral hematoma.

A rare cause of bile duct rupture

Rupture of the biliary tree is usually secondary to hepatobiliary surgery, instrumentation, or abdominal trauma. This 68-year-old lady with no previous medical history presented with pain, vomiting, abdominal distension, and breathlessness of 10 days. She had a large tender lump in the right hypochondrium. Liver function tests were normal and ultrasound showed cholelithiasis and choledocholithiasis along with subcapsular fluid collection in the right lobe of the liver. Contrast-enhancedcomputedtomographyrevealeda massive subcapsular collection in the right lobe (Fig. 1). She was treated with antibiotics, percutaneous drainage of the collection, and stenting of the common bile duct. Imaging revealed also a cutoff of the right biliary system (extrinsic compression) with a normal left biliary system (Fig. 2). She underwent cholecystectomy. Fujiwara et al. in 1998 [1] analyzed 25 cases of spontaneous bile duct rupture and found them to be related to choledocholithiasis, acute cholecystitis, hepatic infarction, liver abscess,sickle cell disease, and tuberculosis. Endoscopic retrograde cholangiopancreatography (ERCP) and stenting is indicated to locate any ongoing leak and bridge the defect or decrease resistance [2].