Subcapsular Hepatic Hematoma Post-Endoscopic Retrograde Cholangiopancreatography Requiring Surgical Necrosectomy

Abstract

Cholelithiasis is a common gastrointestinal pathology with a prevalence of over 6% in the USA. Symptomatic patients can develop cholangitis, biliary colic, pancreatitis and cholecystitis. Surgical management involves laparoscopic or open cholecystectomy. Stones within the common bile duct can be treated with endoscopic retrograde cholangiopancreatography (ERCP). Well-known ERCP complications include pancreatitis, perforation, bleeding and cholangitis. Hepatic hematomas as a complication of ERCP are extremely rare, with fewer than 50 reported cases in the literature. Approximately 22% have required operative management. We present an extremely rare case of ERCP-associated subcapsular hepatic hematoma in a 43-year-old lady that was initially non-operatively managed. She did not improve with antibiotics alone and underwent attempted interventional radiology drainage. Despite this, due to on-going sepsis, the patient underwent laparoscopic necrosectomy and drain placement with continued post-operative irrigation. After a long course of antibiotics and drain irrigation, the patient was discharged with repeated computed tomography imaging showing almost total resolution of the infected collection. This case highlights the extreme rarity of surgical management for post-ERCP subcapsular hepatic hematoma and its successful outcome.

Hepatic subcapsular hematoma: A rare complication post-ERCP; a case report

“…Arterial embolization of the involved vessels can also be taken into account. [18] In our patient, surgery was deemed as too risky due to her labile coagulation blood tests. Arterial embolization was also unavailable in our radiology department.…”

Hepatic hematoma following endoscopic retrograde cholangiopancreatography: overview and case report

“…14 Treatment can be conservative with the patient under close surveillance in an intensive care unit and surgical management is reserved for failures in conservative treatment and cases with hemodynamic instability. 15,16 Privetta et al described a subgroup of patients who had hepatic subcapsular hematoma rupture; showing a significant increase in mortality compared to patients who did not have rupture. 17 It can be concluded that patients who present hematoma rupture require some type of intervention, either by interventional radiology or surgery.…”

Large Hepatic Subcapsular Hematoma Following Endoscopic Retrograde Cholangiopancreatography: A Case Report

“…When a patient has severe anemia and an expanding hematoma, an immediate angiography with angioembolization of bleeding vessels, if detected, should be considered. Surgical treatment should be reserved for patients with ruptured HSH with intraperitoneal collections and signs of peritonitis [ 12 ].…”