Endoscopic retrograde cholangiography-induced subcapsular hepatic hematoma

Gautham Krishnamurthy; Kayalvizhi Jayaraman; Aswin Khanna; Patta Radhakrishna

doi:10.4103/ghep.ghep_19_21

CASE REPORT

Year : 2022 | Volume : 2 | Issue : 1 | Page : 27-29

Endoscopic retrograde cholangiography-induced subcapsular hepatic hematoma

Gautham Krishnamurthy, Kayalvizhi Jayaraman, Aswin Khanna, Patta Radhakrishna
SIGHT - SIMS Institute of Gastroenterology, Hepatology and Liver transplantation, SRM Institute of Medical Sciences, Chennai, Tamil Nadu, India

Date of Submission	01-May-2021
Date of Acceptance	12-Aug-2021
Date of Web Publication	01-Jan-2022

Correspondence Address:
Gautham Krishnamurthy
SRM Institute of Medical Sciences, No. 1, Jawaharlal Nehru Salai, Vadapalani, Chennai - 600 026, Tamil Nadu
India

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ghep.ghep_19_21

Abstract

Endoscopic retrograde cholangiography (ERC)-induced subcapsular hepatic hematoma is a rare but potentially fatal complication. Right hypochondrial pain is the most common symptom and diagnosis is based on imaging after procedure. Majority can be managed successfully with conservative measures. Angioembolization and surgery may be required in hemodynamically unstable patients. We report a case of ERC-induced subcapsular hepatic hematoma detected laparoscopically following endoscopic stone extraction and managed conservatively.

Keywords: Choledocholithiasis, endoscopic retrograde cholangiography, guidewire, hematoma

How to cite this article:
Krishnamurthy G, Jayaraman K, Khanna A, Radhakrishna P. Endoscopic retrograde cholangiography-induced subcapsular hepatic hematoma. Gastroenterol Hepatol Endosc Pract 2022;2:27-9

How to cite this URL:
Krishnamurthy G, Jayaraman K, Khanna A, Radhakrishna P. Endoscopic retrograde cholangiography-induced subcapsular hepatic hematoma. Gastroenterol Hepatol Endosc Pract [serial online] 2022 [cited 2022 Sep 30];2:27-9. Available from: http://www.ghepjournal.com/text.asp?2022/2/1/27/334694

Introduction

Endoscopic retrograde cholangiography (ERC) is frequently performed for managing biliary tract diseases. Complications following ERC have been decreasing with increasing technical expertise and technological innovations.^[1] Common complications include pancreatitis, bleeding, perforation, and cholangitis.^[1] Subcapsular hepatic hematoma is a very rare reported complication. We report a case of ERC-induced subcapsular hepatic hematoma detected laparoscopically and managed conservatively.

Case Report

A 24-year-old gentleman presented with abdominal pain and vomiting for 10 days. Clinical examination was unremarkable. On evaluation with computed tomography (CT), cholelithiasis and choledocholithiasis (7.8 mm) were noted [Figure 1]. Tandem ERC and laparoscopic cholecystectomy (LC) was planned. ERC was performed using a 0.035-inch diameter guidewire. Wide sphincterotomy and balloon trawling was done. Single pigment stone was extracted [Figure 2]. No intraprocedural difficulty or bleeding was noted. During laparoscopy, large nonexpanding subcapsular hematoma was seen in the subdiaphragmatic surface of the liver (Segment 8) [Figure 3]. There was no evidence of increased bleeding suggestive of coagulopathy during cholecystectomy. The patient had an uneventful postoperative period. At 1 month of follow-up, the patient was doing fine.

Figure 1: Computed tomography showing (a) normal subdiaphragmatic surface of the liver. (b and c) Cholelithiasis (solid red arrow) and choledocholithiasis (dotted red arrow) in the terminal common bile duct are seen

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Figure 2: Endoscopic retrograde cholangiography (a) showing filling defect in the distal common bile duct (solid black arrow). (b) Deep cannulation of the guidewire in the bile duct with the distal tip not visualized (dashed black arrow)

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Figure 3: Laparoscopy showing subcapsular hematoma over the subdiaphragmatic surface of the liver (segment 8) (solid black arrow)

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Discussion

Increased availability and improved techniques have made ERC the preferred modality of treatment in choledocholithiasis.^[2] Subcapsular hepatic hematoma is a very rare complication, with 22 cases being reported till 2016.^[3] Hematoma is likely a resultant of rupture of small caliber intrahepatic vessel during guidewire manipulation. The blood tracks through the soft hepatic parenchyma till limited by tough Glisson's capsule. This theory has been supported by the presence of air in hematoma and growth of Citrobacter freundii from hematoma.^[4]

The most common presentation is right hypochondrial pain within 48 h following ERC.^[5] Larger hematomas are accompanied by pallor and hemodynamic instability. Other presentations include fever and peritonism.^[3] Although ultrasound can detect large lesions, CT gives additional details regarding the extent of hematoma, capsule rupture, and possibly provides a road map for angiography if angioembolization of pseudoaneurysm is required.^[2]

From the literature, we found that patients with cholelithiasis and choledocholithiasis had their LC deferred in view of large subcapsular hematoma detected on imaging following ERC for choledocholithiasis.^[6] It is our institution policy to perform tandem ERC and LC for cholelithiasis and choledocholithiasis.^[7] Thus, in contrast to the cases reported in literature, our case had subsequent laparoscopy performed. Continuous monitoring of the distal tip of guidewire and ensuring its presence in the bile duct could have prevented the hematoma.

Conservative approach is successful in majority of patients.^[2],[8] Our patient was monitored for worsening hematoma with clinical assessment, symptomatology, and periodic hemogram. In the absence of evidence of ongoing bleeding, he was discharged. Selective angioembolization of peripheral vessels can be attempted in hemodynamically unstable patients and active bleeding with a high success rate.^[3] Surgical intervention is reserved for patients with deteriorating general conditions, ruptured hematoma, and peritoneal signs.^[3] Percutaneous drainage or surgical drainage may be required in abscess transformation.^[3]

Our patient was asymptomatic for the hematoma. It is likely that hematoma would have been undiagnosed if laparoscopy was not done. We believe that the incidence of ERC-induced subcapsular hepatic hematoma is underreported since small or asymptomatic lesions are likely to be missed. Awareness of this rare but potentially fatal complication can be prevented by gentle handling of guidewire and continuous monitoring of its distal tip.

Conclusion

Subcapsular hematoma following ERC is a rare complication. Conservative management is successful in majority of patients. Gentle handling of guidewire during ERC could possibly prevent this complication.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

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