An unfortunate case of post-ERCP complications

Hepatic subcapsular hematoma post-ERCP: Case report and literature review

INTRODUCTION

Endoscopic retrograde cholangiopancreatography (ERCP) is one of the most frequently performed minimally invasive procedures currently available for diagnosis and treatment of biliary and pancreatic diseases. Though considered a safe procedure, it has the highest rate of complications among the other endoscopic procedures, such as duodenal perforation and hepatic subcapsular hematoma (HSH). We are a presenting a case report and review of the current literature.

METHOD

We report one case HSH rupture, in a 25 years old female patient, 15 cm in diameter, affecting liver segments VI, VII and VIII, who underwent surgical treatment and performed a systematic literature review with the descriptors: endoscopic retrograde colangiopancreatography and hepatic subcapsular hematoma. All articles were reviewed and data on cases that presented rupture of the HSH analyzed separately.

RESULTS

Sixty one cases of HSH were described in the literature, fourteen of them ruptured. When analyzing only the subgroup of patients who had ruptured subcapsular hematoma, we showed a significant increase in the mortality rate of patients when compared to non-ruptured (21.4% × 2.2%). We also report that patients with rupture required some type of intervention, of which 78.6% required surgery. Conservative treatment may be the conduct and will suffice for most cases of non-ruptured hematomas. For patients who evolve with rupturing, surgical resolution, although non-mandatory, is necessary in most cases.

CONCLUSION

HSH ruptured is a rare and potentially fatal post-ERCP complication whose treatment is eminently surgical.

Effectivity of benzydamine hydrochloride gargle to reduce propofol consumption in endoscopic retrograde cholangiopancreatography procedure: a randomized controlled trial

BACKGROUND

Endoscopic Retrograde Cholangiopancreatography (ERCP) is a complex endoscopic procedure that requires moderate to deep sedation. Propofol is the sedative agent of choice for sedation in ERCP due to its fast distribution and fast elimination time without a cumulative effect after infusion, resulting in shorter recovery time. Benzydamine hydrochloride is a topical non-steroidal anti-inflammatory drug that has analgesic, local anesthetic, and anti-inflammatory effects that have been known to be effective in reducing postoperative sore throat. Combination of propofol and topical analgesic may provide adequate sedation and reduce propofol consumption. This study aimed to determine the effectivity of benzydamine hydrochloride gargling in reducing propofol consumption in the ERCP procedure.

METHODS

This study was a single-blind randomized controlled trial for patients undergoing ERCP procedures at Cipto Mangunkusumo Hospital from August to September 2018. A total of 72 subjects were recruited consecutively and randomly assigned into two groups. The first group received 15 mL of 0.15% benzydamine hydrochloride mouthwash prior to the procedure, whereas the second group received 15 mL of water mouthwash. Additional propofol was administered when patient moved or Ramsay Sedation Scale rose above 4. Cumulative propofol consumption per kg body weight per minute and incidence of postoperative sore throat were recorded in each group. Incidence of desaturation, postoperative nausea vomitting, and dysphagia were also recorded. Data analysis was performed with Statistical Package for the Social Sciences.

RESULTS

Cumulative propofol consumption per minute per kg body weight in the benzydamine hydrochloride group was 152.7 (91.9-238.8) mcg/kg/minute, while in the control group was 200.05 (114.4-380.2) mcg/kg/ minute (p = < 0.001). The incidence of sore throat on the 0th, 2nd, and 4th hour for the benzydamine hydrochloride group was 11.4, 11.4, and 5.7%, while in the control group was 50, 52.8, and 36.1% (p = < 0.001, < 0.001, 0.003). Desaturation was found in control group whereas none in benzydamine hydrochloride group. Complaints of nausea and vomiting were comparable in both groups.

CONCLUSION

Benzydamine hydrochloride gargling was effective in reducing cumulative propofol consumption in the ERCP procedure.

TRIAL REGISTRATION

Study was registered retrospectively in ClinicalTrials.gov with NCT04167592 on November 8th 2019.

Systematic review: Features, diagnosis, management and prognosis of hepatic hematoma, a rare complication of ERCP

BACKGROUND

Hepatic hematoma (HH) is a rare but severe adverse event following endoscopic retrograde cholangiopancreatography (ERCP).

AIMS

To perform a systematic literature review and describe two additional cases, one of which presenting multiple subcapsular/intrahepatic hematomas after ERCP.

METHODS

The literature review was performed in PubMed/MEDLINE, EMBASE, and SCOPUS to identify all cases reporting on HH after ERCP.

RESULTS

A total of 48 cases (females 63%, mean age 58.2 ± 20.6 years) were included. The mean symptoms onset time was 46.8 h after ERCP, and the most common symptoms were abdominal pain (91.7%), anaemia (43.8%), hypotension (29.2%) and fever (20.8%). All cases were diagnosed by computed tomography (CT). HH was found mostly in the right hepatic lobe (95.1%) and the mean size was 116 × 93 mm. A conservative management was adopted in 38.3% of cases, while percutaneous drainage, embolization and surgery were needed in 31.9%, 14.9% and 25%. Mortality rate was about 9%. Anaemia (OR 6.9; p = 0.02) and surgery (OR 10.5; p < 0.01) were the only independent factors for unfavorable outcome (death), while abdominal pain (OR 0.1; p = 0.03) and antibiotics administration (OR 0.06; p < 0.001) were associated with better outcome.

CONCLUSIONS

HH is a rare but severe complication following ERCP which needs a multidisciplinary approach. Antibiotics administration is the only treatment able to reduce the risk of death.

Rare case of hepatic haematoma following endoscopic retrograde cholangiopancreatography

Endoscopic retrograde cholangiopancreatography (ERCP) is a commonly used diagnostic and therapeutic technique but it is not free of complications. Subcapsular hepatic haematoma is a rare but potentially fatal complication. A 71-years-old male patient resorted to the emergency department 36 hours after an uneventful ERCP presenting with severe abdominal pain and haemoglobin drop. Abdominal ultrasound and CT scan diagnosed a subcapsular hepatic haematoma. The patient was haemodynamically normal and was successfully treated with a conservative management. Signs and symptoms of hepatic haematoma following ERCP are non-specific. The most common symptom is abdominal pain. Abdominal CT, ultrasound or MRI make the diagnosis. Conservative management is possible if the patient is stable, nevertheless invasive treatment such as surgery or angiographic embolisation, may be required. A low threshold of suspicion is crucial for an early diagnosis and treatment. Fatal cases have been described but most patients have a favourable outcome.