Endoscopic retrograde cholangiopancreatography (ERCP) is an invasive procedure with significant complications. Splenic hematoma is an extremely rare but known complication following ERCP that has been increasingly reported in the past several years. We report the case of a 44-year-old patient with a history of sleeve gastrectomy who underwent an ERCP that was complicated by both acute pancreatitis and splenic hematoma. She was managed conservatively under close monitoring in the intensive care unit. Clinicians should be aware of this potentially life-threatening complication to make a prompt diagnosis and begin early appropriate management.

Neurofibromatosis type 1 is an autosomal dominant neurocutaneous disorder characterized by a mutation of the neurofibromin 1 (NF1) gene, resulting in increased susceptibility for multiple tumors, namely, gastrointestinal stromal tumors (GISTs)—the most common types of mesenchymal neoplasms in the gastrointestinal tract. Despite these tumors' predilection for the stomach, it seems to be the least likely part of the gastrointestinal (GI) tract to be affected in cases of neurofibromatosis. Herein, we report a case of a 61-year-old male patient with known neurofibromatosis, who presented with acute blood loss anemia due to a recurrent gastric GIST, requiring partial gastrectomy due to its size and multiple recurrences.

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A 63-year-old man had previously undergone resection for stage III colon cancer. Liver metastasis had resolved with palliative chemotherapy. The patient was now admitted because of weight loss, obstructive jaundice, and intrahepatic and extrahepatic biliary dilatation due to extrinsic compression of the biliary tree at the porta hepatis. Endoscopic retrograde cholangiography (ERCP) was performed with placement of a fully covered metal stent in the common bile duct and right hepatic duct, and the patient was discharged with downward-trending bilirubin levels. However, 10 days later, he was readmitted with dyspnea, abdominal pain, and a temperature of 100.1°F. Physical examination revealed chest pain at the left lower ribs and epigastric tenderness. Laboratory test results were white blood cell count 21.3 × 10 9 /L, bilirubin 7.6 mg/dL, alkaline phosphatase 212 U/L, and blood cultures positive for Clostridium perfringens (• " Fig. 1). Computed tomography of the abdomen showed a 3.1-cm collection of fluid that contained gas in the left lobe of the liver (• " Fig. 2). Inadequate drainage of the left hepatic system due to blockage by the stent in the right hepatic duct may have created a nidus for infection. The patient was successfully treated with intravenous antibiotics, abscess drainage, and removal of the metal stent (• " Fig. 3). C. perfringens is a rapidly growing (doubling time of 7 minutes), spore-forming, anaerobic, Gram-positive bacillus that is often found in the human bowel but rarely causes liver abscess and sepsis. To the best of our knowledge, approximately 22 cases of C. perfringens liver abscess resulting in septicemia have been reported, many of which were fatal [1]. The infections that lead to septicemia after ERCP are most commonly caused by Escherichia coli, Pseudomonas aeruginosa, and Klebsiella pneumoniae, but rarely C. perfringens [1]. C. perfringens infection has a mortality rate of 70 % to 100 %, often develops in immunosuppressed patients, and presents with fever, abscess, or hemolysis [2]. Liver abscess due to C. perfringens is a rare and often fatal event; a high degree of suspicion for the diagnosis and immediate treatment with drainage and antibiotics are required.

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