Journal Name: International Journal of Hepatobiliary and … · 2018. 12. 7. · 36 Endoscopic...

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Early View Article: Online published version of an accepted article before publication in the

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Journal Name: International Journal of Hepatobiliary and Pancreatic Diseases (IJHPD)

Type of Article: Case Report

Title: Subcapsular Left Hepatic Lobe Hematoma: A potentially life-threatening post-ERCP

complication. Case report

Authors: Alzubaidi AM, Alshadadi AA, Atta MF, Alsareii SA

doi: To be assigned

Early view version published: May 9, 2017

How to cite the article: Alzubaidi AM, Alshadadi AA, Atta MF, Alsareii SA. Subcapsular

Left Hepatic Lobe Hematoma: A potentially life-threatening post-ERCP complication. Case

report. International Journal of Hepatobiliary and Pancreatic Diseases (IJHPD).

Forthcoming 2017.

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TYPE OF ARTICLE: Case Report 1

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TITLE: Subcapsular Left Hepatic Lobe Hematoma: A potentially life-threatening 3

post-ERCP complication. Case report 4

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AUTHORS: 6

Alzubaidi AM1, Alshadadi AA 1, Atta MF1, Alsareii SA2 7

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AFFILIATIONS: 9 1King Khalid Hospital –Najran/Gastroenterology /Saudi Arabia 10 2Faculty of Medicine –Surgical Department -Najran University /Saudi Arabia 11

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CORRESPONDING AUTHOR DETAILS 13

Dr.Ali Mothanna Saleh Al-zubaidi 14

Consultant Gastroenterology & Hepatology King Khalid hospital –Najran 15

Clinical Assistant Professor Faculty of Medicine/Najran University /Saudi Arabia 16

Email: [email protected] 17

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Short Running Title: NOT GIVEN 19

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Guarantor of Submission : The corresponding author is the guarantor of 21

submission. 22

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34

ABSTRACT 35

Endoscopic retrograde cholangiopancreatography (ERCP) is minimally invasive 36

procedure commonly performed for biliary and pancreatic diseases. According to the 37

literature, the most common related complication are: pancreatitis, post-38

sphincterotomy bleeding, perforation and cholangitis, This is rare and exceptional 39

ERCP complication and only few cases have been reported.We report a case of 40

rare post-ERCP complication, subcapsular liver hematoma that was diagnosed 16 41

hour post-ERCP in 28-year old lady with intra-abdominal collection, U/S guided 42

drainage of suspected bile leak was done ,but the drained fluid was bloody, with 43

total amount of 900ml in the first 36 hours (Analysis its blood mixed with bile), 44

Patient received 2unit packed RBCs and she maintain her vital sign and 45

Hemoglobin at 8.5g/dl. 46

CT Abdomen was done and revealed large left hepatic lobe subcapsular hematoma 47

16 x7 x 12 cm with no active bleeding causing compression of the left hepatic 48

vessels. 49

On the basis of laboratory, clinical, and hemodynamic parameters the patient was 50

hemodynamically stable. She was managed conservatively with only U/S guided 51

drained of abdominal collection and no any radiological or surgical intervention 52

needed for the hematoma. 53

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Keywords: Endoscopic Retrograde cholangiopancreatography, Subcapsular 55

hematoma, post-ERCP complication. 56

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65

INTRODUCTION 66

Endoscopic retrograde cholangiopancreatography (ERCP) is one of the most 67

frequently performed therapeutic procedures for biliary and pancreatic diseases. 68

ERCP-related complications around 2.5% to 9%, with a mortality rate ranging from 69

0.6% to 1 %.[1]. Post-ERCP Pancreatitis, perforation, cholangitis and post-70

sphincterotomy bleeding are the most frequently described complications 71

[2,3].Rare unexpected post-ERCP complication such as Subcapsular hepatic 72

hematoma was firstly described in 2000 [4].although it's rare but its potential life 73

threatening condition.We report an unusual case of left hepatic lobe subcapsular 74

hematoma after ERCP presenting with a drop in hemoglobin, tachycardia and intra-75

abdominal collection. 76

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CASE REPORT 78

A 28-year-old female patient was referred to us as a case of obstructive jaundice 79

caused by common hepatic duct stricture misdiagnosed as choledocholithiasis by 80

ultrasound abdomen. She was admitted for ERCP. Proper biliary drainage was done 81

after dilatation of common hepatic duct stricture by dilator catheter up to 10 French 82

with the placement of plastic stent 10french 10cm length without immediate 83

complications(Figure1Arrow A), the Second day after the procedure the patient 84

complained of mild abdominal pain and fullness in the epigastric area. She 85

developed tachycardia (PR 115 beats per minute & BP = 100/60mmHg) with a drop 86

of hemoglobin of 2g/dl without melena or hematemesis. 87

Laboratory tests revealed a normal white blood cell count (8.5× 109/L) and drop in 88

hemoglobin level (from 9 to7 g/dL),platelets = 243,INR = 1.4 ,total bilirubin = 214 89

umol/L, direct bilirubin = 176 umol, AST = 55 u/L , ALT = 60 u/l,ALP = 174 u/L, GGT 90

= 90 u/L and Normal S.Amylase level. 91

Abdominal U/S Showed free fluid in the abdomen with a subscapular liver collection. 92

U/S guided drainage of suspected bile leak was done it drained (Figure1Arrow b). 93

Bloody fluid with a total amount of 900ml drained in the first 36 hours (Analysis its 94


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blood mixed with bile), four days there after the drain became dry after which the 95

abdominal catheter was removed. The patient received 2 unit of packed RBCs and 96

she maintained her vital signs and Hb around 8.5g/dl. CT Abdomen was done and 97

revealed large left hepatic lobe subcapsular hematoma 16*7*12 cm with no active 98

bleeding causing compression of the left hepatic vein with capsule tension (Figure2). 99

The patient was kept on broad spectrum antibiotics. On the third day, she 100

complained of abdominal discomfort and vomiting which could be attributed to 101

compression of the stomach and proximal duodenum by the hematoma as shown in 102

(Figure3). 103

On the basis of the laboratory, clinical, and hemodynamic parameters; the patient 104

was hemodynamically stable. She was managed conservatively with only U/S guided 105

drained of abdominal collection and no any radiological or surgical intervention 106

needed for the hematoma. 107

Her follow-up CT abdomen at day 8 showed most of the hematoma organized 108

(Figure4). And patient discharged home at day 20 of hospitalization with close follow-109

up in OPD. 110

111

DISCUSSION 112

Subcapsular hepatic hematoma is a rare unexpected and potentially life-threatening 113

complication after ERCP. It was firstly described by Ortega et al.[ 4 ]in 2000 who 114

diagnosed subcapsular hematoma in 81-year-old man with abdominal pain after 115

ERCP for CBD stone. 116

The etiology of the hematoma is not entirely clear. Most of the authors claimed that it 117

is caused by rupture of small caliber vessels due to the guide wire trauma [5,6,7 ]. In 118

our case guide, wire is the most probable cause as it appears in (Figure5). 119

Abdominal pain associated with hypotension and tachycardia after ERCP should 120

raise the suspicion of intrahepatic bleeding with capsule distension. Different 121

symptoms are described in literature: abdominal pain (91%), hypotension (39.1%), 122

anemia (39.1%), fever (21.7%) and peritonism (13%) [8 ].In our case patient has 123

epigastric pain, anemia, tachycardia and vomiting which could be attributed to 124

stomach & duodenal compression. CT and ultrasound are the gold standard 125

radiological modalities for diagnosis and surveillance of this complication [9]. 126


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No laboratory test provide reliable indicators of the development of a subcapsular 127

hepatic hematoma, except for a decrease in the hemoglobin level[10.11].The 128

Management is conservative for most of the cases as we did in our case. As the 129

Glisson’s capsule of the liver-confined the hematoma and prevents more bleeding. 130

However large hematomas may require percutaneous drainage for symptomatic 131

relief [12,7]. Management of the 25 cases reported up to now (41.5% cases 132

conservative, percutaneous drainage (25%), Embolization (21%), and surgical 133

intervention only in three cases 12.5%). As the guide wire may be sources of 134

infection we recommend prophylactic broad spectrum antibiotics for these patients to 135

prevent hematoma infection and abscess formation. In our case hematoma did not 136

increase and hemodynamics of the patient remained stable, so she did not require 137

embolization or surgical intervention. 138

In the case of hemodynamic instability, different therapeutic approaches including 139

minimally invasive radiological intervention such as selective vessels embolization 140

showed high success rates[13]. Surgical approach consist of hematoma evacuation, 141

local hemostasis with electrocoagulation or hemostatic devices, or packing in case of 142

massive hemorrhage[14] 143

144

CONCLUSION 145

Rare ERCP complications like liver subcapsular hematoma must be kept in mind if 146

the patient complains of right upper quadrant pain or develops hemodynamic 147

instability. Treatment is mostly conservative. As the guide wire may be sources of 148

infection we suggest prophylactic antibiotic because hematoma is liable to get 149

infection and abscess formation, with follow-up by serial CT scans. 150

Hepatic artery embolization and surgery should be performed early in case of 151

hemodynamic instability or increasing size of hematoma. We concluded that guide 152

wire injury of the hepatic vessels is the most probably causative agent and 153

avoidance of deep insertion of the guide wire may decrease the risk of such 154

catastrophic complication. 155

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CONFLICT OF INTEREST 159

Ali Mothanna Al-zubaidi, Abdulfattah A Alshadadi, Muhammad Farook Atta and 160

Saeed Alsareii declare no conflicts of interests. 161

162

AUTHOR’S CONTRIBUTIONS 163

NOT GIVEN 164

165

REFERENCES 166

1. Zizzo M, Lanaia A, Barbieri I, Zaghi C, Bonilauri S. Subcapsular Hepatic 167

Hematoma After Endoscopic Retrograde Cholangiopancreatography: A Case 168

Report and Review of Literature. Medicine (Baltimore) [Internet]. Wolters 169

Kluwer Health; 2015 Jul [cited 2016 Dec 30]; 94(26):e1041. Available from: 170

http://www.ncbi.nlm.nih.gov/pubmed/26131812 171

2. Cotton PB, Garrow DA, Gallagher J, Romagnuolo J. Risk factors for 172

complications after ERCP: a multivariate analysis of 11,497 procedures over 173

12 years. Gastrointest Endosc [Internet]. 2009 Jul [cited 2016 Dec 30]; 174

70(1):80–8. Available from: http://www.ncbi.nlm.nih.gov/pubmed/19286178 175

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MA, Martínez Santos C, Moreno Azcoita M. Liver hematoma following 181

endoscopic retrograde cholangiopancreatography (ERCP). Surg Endosc 182

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http://www.ncbi.nlm.nih.gov/pubmed/11287996 184

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connect.de/DOI/DOI?10.1055/s-0031-1291493 189


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6. Petit-Laurent F, Scalone O, Penigaud M. Sub-capsular hepatic hematoma 190

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FIGURE LEGENDS 232

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Figure 1: Plain CT shows plastic CBD stent (A)- lobe and intra-abdominal drain (B)- 234

in place 235

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Figure 2: CT abdomen shows left liver Subcapsular Hematoma (Arrow) 237

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Figure 3: Shows the hematoma reaching to the left abdominal wall causing 239

compression of the stomach and proximal small bowel. 240

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Figure 4: Abdominal CT day 8 shows heterogeneous hematoma due to clot 242

formation. 243

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Figure 5: Deeply inserted ERCP Guide wire 0.035 inch into left liver lobe 245

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FIGURES 254

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Figure 1: Plain CT shows plastic CBD stent (A)- lobe and intra-abdominal drain (B)- 258

in place 259

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Figure 2: CT abdomen shows left liver Subcapsular Hematoma (Arrow) 263

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A

B


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Figure 3: Shows the hematoma reaching to the left abdominal wall causing 267

compression of the stomach and proximal small bowel. 268

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Figure 4: Abdominal CT day 8 shows heterogeneous hematoma due to clot 272

formation. 273

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Liver subcapsular hematoma causing

compression of the stomach

Compressed stomach


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Figure 5: Deeply inserted ERCP Guide wire 0.035 inch into left liver lobe 277

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