Subcapsular hepatic haematoma after endoscopic retrograde cholangiopancrea-tography: An unusual case

Hepatic subcapsular hematoma following endoscopic retrograde cholangiopancreatography. Report of two cases

INTRODUCTION AND IMPORTANCE

Hepatic subcapsular hematomas (HSH) are an extremely rare post-endoscopic retrograde cholangiopancreatography (ERCP) complication. Mortality exhibits disparities depending on the integrity of the hepatic capsular envelope, with ruptured HSH being associated with higher case fatality rates (2.2 % compared to 21.4 %).

CASES PRESENTATION

Two clinical cases are presented concerning a 20-year-old female patient and a 40-year-old male patient, who were diagnosed with choledocholithiasis and underwent ERCP procedures with the use of a wide-bore guidewire (WBG), with the undesired result of HSH as a complication. In both scenarios, a surgical approach strategy was chosen to manage this situation. The outcome turned out to be successful in the first case, in contrast to the unfortunate death of the patient in the second case.

CLINICAL DISCUSSION AND CONCLUSIONS

Conservative approaches prevail in the management of HSH, as they often present intact, resulting in a low mortality rate. However, surgical approaches are reserved for consideration in situations of hemodynamic instability that persists despite the conservative measures implemented.

Rare post-endoscopic retrograde cholangiopancreatography complications: Can we avoid them?

Regarded as a minimally invasive procedure, endoscopic retrograde cholangiopancreatography (ERCP) is commonly used to manage various pancreaticobiliary disorders. The rate of complications is low and starts from 4% for diagnostic interventions. The group of most frequent negative outcomes is commonly known and includes pancreatitis, cholecystitis, and hemorrhage. Rare adverse effects occur occasionally but carry a significant risk of unexpected and potentially dangerous results. In some cases, including splenic injury, the knowledge of pre-existing conditions might be helpful in avoiding the unwanted outcome, while in others, the risk factors are not clearly defined. Such situations demand increased caution in the post-ERCP period. The appearance of abdominal pain, peritoneal symptoms, or instability of the patient’s hemodynamic condition should alert the physician and lead to further investigation of the possible causes. The diagnostic process usually involves imaging tests. The implementation of the appropriate treatment should be immediate, as many of the rare complications carry the risk of dangerous, even potentially lethal, results.

Endoscopic ultrasonography drainage and debridement of an infected subcapsular hepatic hematoma: A case report

BACKGROUND

Endoscopic ultrasonography (EUS) has evolved in the last years making it not only a diagnostic modality but a therapeutic procedure. EUS is now used as an alternative technique to percutaneous and surgical drainage. Even though EUS is a challenging procedure and not always suitable compared to percutaneous drainage, there is a need for developing new therapeutic approaches to the liver for when percutaneous drainage is not feasible.

CASE SUMMARY

We present the case of a 82 years old male who developed an infected subcapsular hepatic hematoma (SHH) of the left lobe following percutaneous biliary drainage. After 2 failed attempts of percutaneous drainage of the SHH and because the patients couldn’t withstand surgery, we conducted a EUS drainage and debridement of the SHH. Using a lumen apposing metal stent (LAMS) by a transgastric approach, we were able to gain endoscopic access to the SHH. With our experience in the debridement of walled off pancreatic necrosis using this technique, we were confident it was the right approach. After four debridement sessions, the computed tomography scan showed a clear regression of the SHH.

CONCLUSION

To our knowledge, this is the first case of successful endoscopic debridement of a SHH using a LAMS which appear to be feasible and safe in this specific case.

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.

Subcapsular Hepatic Hematoma Post-ERCP: Case Report and Review of the Literature

INTRODUCTION

Hepatic hematoma is a rare but possible complication of ERCP. We describe the case of a 75-year old man with a large, 8 × 12 cm, sub-capsular and intra-parenchymal hematoma post ERCP, affecting the right liver segments and treated conservatively.

AREAS COVERED

A review of literature has been performed, highlighting two possible mechanisms: hematoma may occur as the result of accidental laceration of a small intrahepatic vessel by the guidewire, whereas the other hypothesis posits that the hepatic damage is secondary to traction on the biliary system exerted by the balloon. We speculate that in case of anomalies of the biliary tree, the incidence of this complication is higher than expected.

EXPERT COMMENTARY

In case of hepatic hematoma post ERCP, a conservative approach should always be considered before proceeding to interventional radiologic procedures or to surgical therapy.

Post-ERCP hepatic subcapsular hematoma, from conservative therapy to emergency surgery: an unusual though extremely serious complication

Based on two clinical cases that developed subcapsular hematoma after ERCP procedure and resolved each one differently (conservative management and surgery, respectively) we have made a brief review of current status, risk factors and treatment options. We also summarize the cases that required surgery. With the increase of endoscopic procedures, it is important to consider this type of major and severe complication.

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.

Isolated Arteries Originating from the Intrahepatic Arteries: Anatomy, Function, and Importance in Intervention

Isolated hepatic arteries are defined as hepatic terminal arterioles that are not accompanied by portal venules or bile ductules and penetrate the liver parenchyma and distribute to the hepatic capsule and intrahepatic hepatic veins. Abundant communications exist between intra- and extrahepatic arteries through isolated arteries and capsular arterial plexus. They play a principal role in the development of subcapsular hemorrhage and arterial collateral formation following transcatheter arterial chemoembolization for liver cancers. The anatomy, function, and clinical importance of isolated hepatic arteries in interventional radiology, especially regarding subcapsular hemorrhage and arterial collateral formation, are highlighted in this article.

Intrahepatic subcapsular biloma after endoscopic retrograde cholangiopancreatography treated by endoscopic biliary drainage

Several major complications from endoscopic retrograde cholangiopancreatography (ERCP), including pancreatitis, cholangitis, and hemorrhage have been discussed in detail; however, a few uncommon but severe complications have been reported. We encountered an unusual case of post-ERCP intrahepatic subcapsular biloma. An 89-year-old woman with a 25-mm mass located at the hepatic hilum, suggestive of cholangiocarcinoma, underwent ERCP which demonstrated complete stricture of the common hepatic duct. Subsequently, two plastic stents were placed from the common bile duct to the right and left intrahepatic branches. On day 3, serum inflammatory markers were elevated and computed tomography revealed a large subcapsular fusiform fluid collection in the right liver, consistent with biloma. On day 6, the biloma ruptured and 500 ml of biliary ascites were removed. On day 8, endoscopic nasobiliary drainage via the right intrahepatic branch was performed because of recurrence of biliary ascites. After the procedure, 150 ml of bile was collected through the drain every day and no ascites recurred. We believe that minor injury to the right intrahepatic bile duct due to guidewire manipulation caused the biloma. Biloma may become apparent several days after ERCP, and endoscopic biliary drainage placement adjacent to the bile duct rupture site can stop bile leakage.

A post-endoscopic retrograde cholangiopancreatography subcapsular hepatic hematoma

Nowadays endoscopic retrograde cholangiopancreatography (ERCP) is a minimally invasive technique with a complication rate around 2.5% in expert hands, being the most frequent: acute pancreatitis, cholangitis, hemorrhage and perforation. An exceptional complication is subcapsular hepatic hematoma, first published in the literature in 2000, with few cases reported. Regarding the case published by Del Moral Martínez et al (Hepatic Hematoma after ERCP: presentation of two new cases. Rev Esp Enferm Dig 2017, Vol. 109, No. 6, pp. 470-473) we would like to contribute a reflection based on a recent clinical case in our center.

ERCP-related complication is not the only cause of GI bleeding in post-liver transplantation patients: A case report

RATIONALE

Endoscopic retrograde cholangiopancreatography (ERCP) is the treatment of choice for biliary complications in liver transplantation (LT) recipients as it is both diagnostic and therapeutic. The specific risks following ERCP among LT recipients have not been well studied.

PATIENT CONCERNS

A 56-year-old man with a history of orthotopic LT underwent endoscopic retrograde cholangiopancreatography (ERCP) as a treatment of biliary strictures, whereby a plastic stent was implanted. Thirteen days after ERCP the patient developed multiple episodes of hematemesis.

DIAGNOSIS

Digital subtraction angiography (DSA) of the hepatic artery and superior mesenteric artery showed a hepatic pseudoaneurysm (PA) in the left hepatic artery. The final diagnosis was bleeding from the PA.

INTERVENTION

Interventional embolization of the branch with PA was performed to stop the bleeding.

OUTCOME

The patient remained free of GI bleeding for 25 days after interventional embolization, but he developed another bout of bleeding and unfortunately passed away.

LESSONS

ERCP-related complication is not the only cause of post-ERCP bleeding, and that other primary causes should also be ruled out.

Subcapsular hepatic haematoma of the right lobe following endoscopic retrograde cholangiopancreatography: Case report and literature review

Sub capsular hepatic haematoma is a rare complication after endoscopic retrograde cholangiopancreatography (ERCP). Exact pathological mechanism is still unclear and few reports are nowadays available in literature. We report the case of a 58-year-old woman with recurrent episodes of upper abdominal pain, nausea and vomiting. On the basis of laboratory exams, abdomen ultrasound and magnetic resonance imaging she was diagnosed with a common bile duct stone. Endoscopic biliary sphincterotomy was performed. On the following day the patient complaint severe abdominal pain with rebound and hemodynamic instability. A computed tomography scan reveal a 14 cm × 6 cm × 19 cm sub-capsular hepatic haematoma on the right lobe that was successfully managed via percutaneous embolization. Sub capsular liver haematoma is a rare life threatening complication after ERCP that should be managed according to patients’ haemodynamic and clinic.

[Surgical treatment for liver haematoma following endoscopic retrograde cholangiopancreatography; An unusual case]

BACKGROUND

Even in expert hands, there can be serious complications when performing an endoscopic retrograde cholangiopancreatography. The most frequent complications are pancreatitis, cholangitis, bleeding, perforation, and acute cholecystitis. The hepatic subcapsular haematoma is a rare complication, with few cases described worldwide.

OBJECTIVE

A case is presented of an extremely rare complication of endoscopic retrograde cholangiopancreatography, which required surgical treatment for its resolution without success. This is second case of mortality reported in the literature.

CLINICAL CASE

Female patient of 30 years old, with indication for endoscopic retrograde cholangiopancreatography due to benign strictures. A hydro-pneumatic dilation and stent placement of 2 gauge 10 fr was performed. She presented abdominal pain after the procedure and significant decline in haemoglobin with no evidence of haemodynamic instability so an abdominal tomography scan was performed, showing no evidence of liver injury. The patient was haemodynamic unstable within 72 h. A laparotomy was required for damage control, with fatal outcome in the intensive care unit due to multiple organ failure.

CONCLUSION

Subcapsular hepatic haematoma after endoscopic retrograde cholangiopancreatography is a rare complication, with few cases reported in the literature. Treatment described in the literature is conservative, resulting in a satisfactory resolution.

Subcapsular Hepatic Hematoma After Endoscopic Retrograde Cholangiopancreatography: A Case Report and Review of Literature

Endoscopic retrograde cholangiopancreatography (ERCP) is one of the most frequently performed procedures for the diagnosis and treatment of biliary-pancreatic diseases. ERCP-related complications total around 2.5% to 8%, with a mortality rate ranging from 0.5% to 1%. An exceptional ERCP complication is subcapsular hepatic hematoma, and few cases are reported worldwide.We present the case of a 52-year-old woman with a history of recurring upper abdominal pain and a clinical and ultrasonographic diagnosis of obstructive jaundice due to common bile duct stones. After 2 difficult endoscopic biliary procedures, common bile duct stones clearance was obtained. Post-ERCP course was symptomatic with upper abdominal pain and anemization with hemodynamic instability.CT scan demonstrated a 15 cm × 11 cm subcapsular hepatic hematoma filled with air and liquid on the surface of the right hepatic lobe. The patient was successfully treated with the embolization of a small branch of right hepatic artery angiographically identified as the cause of bleeding.Subcapsular hepatic hematoma after ERCP is a rare complication that must be taken into account in the differential diagnosis of symptomatic cases after ERCP. Its diagnosis is based on clinical and laboratory data and especially on imaging (ultrasound, CT, or MRI). Treatment is often conservative but, in some cases, embolization or percutaneous drainage or surgery may be necessary.

Uncommon and rarely reported adverse events of endoscopic retrograde cholangiopancreatography

Endoscopic retrograde cholangiopancreatography (ERCP) has become a primary tool for the treatment of biliary and pancreatic ductal diseases. It is essential for the endoscopist carrying out the ERCP to have a thorough understanding of the potential adverse events. Typically, endoscopists are well familiar with common adverse events such as post-ERCP pancreatitis, cholangitis, post-sphincterotomy bleeding, post-sphincterotomy perforation, and sedation-related cardiopulmonary compromises. However, there are other less common adverse events that arecritical to promptly recognize in order to provide appropriate therapy and prevent disastrous outcomes. This review focuses on the presentation and management of the less common and rare adverse events of an ERCP from the perspective of the practicing endoscopist.