Hemorrhagic complications following endoscopic retrograde cholangiopancreatography
(ERCP) are generally manifest as gastrointestinal hemorrhage, and published studies
report an incidence of 0.8 % to 4 % [1]
[2].
Intrahepatic bleeding as a complication of ERCP has not been reported previously,
although guide wire perforation of the biliary tree resulting in intrahepatic biloma
and intraperitoneal bleeding from gastroduodenal, pancreatoduodenal, and hepatic arteries
has been described [3]
[4]
[5]. This case illustrates an unreported complication of ERCP resulting in significant
morbidity.
A 51-year-old female presented with right-sided abdominal discomfort, and tender hepatomegaly
extending to the right iliac fossa 3 months after an ERCP for a retained common bile
duct stone and jaundice. Following duct cannulation and contrast injection, a tracer
guide wire was maneuvered past the stone, and a 1 cm sphincterotomy was carried out,
and the stone retrieved following a single balloon trawl. The patient had normal hematological
and clotting parameters. Following the procedure the patient developed right upper
abdominal pain and collapsed requiring intensive resuscitation. Hyperamylasemia was
absent. An urgent computed tomography (CT) scan revealed a large collection (10 ×
13 cm) consistent with a hematoma within the lateral inferoposterior aspect of the
right lobe of the liver. Ultrasound-guided drainage of blood was performed with a
pigtail catheter. Ultrasonographic monitoring was performed at 1 and 3 months, revealing
an increase in size of the hematoma from 17 × 15 × 9 cm to 23 × 18 × 16 cm serially.
Contrast-enhanced CT was performed and showed the lesion to be entirely intrahepatic
([Figure 1]). Under ultrasound guidance, 5600 ml of bile-free liquid hematoma was drained percutaneously,
with successful resolution at 3 months of follow up. This case was managed successfully
using a percutaneous drainage; however, this approach does raise the possibility of
further hemorrhage following drainage, and is only recommended where facilities for
embolisation and surgery exist.
Figure 1 Large subcapsular intrahepatic hematoma after endoscopic retrograde cholangiopancreatography.
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