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Letter to the Editor
Melena after endoscopic retrograde cholangiopancreatography: A warning sign of an impending subcapsular hepatic hematoma
Melena posterior a colangiopancreatografía retrógrada endoscópica: un signo de alarma de inminente hematoma hepático subcapsular
José Obeth Montoya Rojo, Marcos Antonio Amezcua Gutiérrez
Corresponding author
amezcua_20@hotmail.com

Corresponding author.
, Jorge Alberto Castañón-González
Intensive Care Unit, Hospital Juárez de México OPD, Mexico City, Mexico
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">The most frequent indication for urgent endoscopic retrograde cholangiopancreatography &#40;ERCP&#41; is obstruction due to biliary stone that requires sphincterotomy&#46; Among ERCP complications&#44; subcapsular hepatic hematoma &#40;SHH&#41; is rare and life threatening complication that requires high level of suspicious for diagnosis&#46; A recent review by Zappa et al&#46;&#44; reports that sudden abdominal pain &#40;91&#37;&#41;&#44; hypotension &#40;39&#46;1&#37;&#41; and anemia &#40;39&#46;1&#37;&#41; after ERCP should guide to the diagnosis&#59; other signs and symptoms include fever &#40;21&#46;7&#37;&#41; and peritonism &#40;13&#37;&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">1</span></a> This varied clinical presentation can be misleading&#44; delaying diagnosis and prompt resolution&#46; Herein we describe a case in which melena due to significant hemobilia was the preceding sign of an evolving SHH after ERCP&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">A 25-years old female with a history of abdominal pain&#44; fever and jaundice underwent an urgent ERCP and sphincterotomy for choledocholithiasis&#46; 24<span class="elsevierStyleHsp" style=""></span>h post-ERCP she complained of mild abdominal pain&#44; melena and palpitations&#46; An evaluation confirmed melena and a hemoglobin drop of 3<span class="elsevierStyleHsp" style=""></span>g&#47;dL&#46; An esophago-gastro-duodenoscopy ruled out active peptic disease&#59; a big clot was seen in the major duodenal papilla&#44; therefore sclerotherapy with epinephrine was done and 48<span class="elsevierStyleHsp" style=""></span>h after procedure&#44; intensive care unit &#40;ICU&#41; evaluation was requested&#59; the patient was on shock and high dose vasopressors&#44; laboratory test reported a total hemoglobin drop of 6<span class="elsevierStyleHsp" style=""></span>g&#47;dL&#44; hematocrit 18&#37;&#44; metabolic acidosis and hyperlactatemia&#46; Abdominal ultrasound with FAST protocol &#40;Focused Assessment with Sonography in Trauma&#41; showed 100&#37; inferior vena cava collapsibility&#44; free fluid in the hepatorenal&#44; perisplenic and suprapubic recesses&#59; also with an intracapsular anechoic liver image suggestive of a left lobe SHH&#44; which was confirmed by an abdominal computed tomography scan&#46; An exploratory laparotomy was performed&#46; Surgery findings were a massive 1500<span class="elsevierStyleHsp" style=""></span>mL hemoperitoneum due to a left hepatic lobe ruptured hematoma&#46; After abdominal packing and closure&#44; she was admitted to the ICU on shock&#46; Multiple red blood packages and fresh frozen plasma were transfused&#46; Despite aggressive reanimation in the intensive care&#44; bleeding persisted and she died on hypovolemic shock after a second surgery&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Inadvertent guide wire perforation of the biliary tree during ERCP should be suspected in any patient with abdominal pain and anemia after the procedure&#44; because an early diagnosis carries low death rates&#46; To our knowledge melena has not been reported as a companion of SHH&#44; therefore we will like to include it as a sign of severe biliary tree damage&#59; because it reflects significant hemobilia and therefore an impending SHH should be ruled out&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Recently&#44; Alzubaidi et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">2</span></a> reported a left hepatic lobe SHH as in our case but almost all reported are on right lobe&#46; Perforation of the biliary tree and small hepatic vessels injury with the metallic guide wire during the procedure occurred in around 95&#37; of the reported cases&#46;<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">1&#8211;4</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Although SHH it is considered a life threatening condition&#44; low death rates are reported associated to an early diagnosis and treatment by embolization&#46; Zizzo et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">4</span></a> reported 47&#46;6&#37; of patients treated conservatively&#44; 23&#46;8&#37; with percutaneous drainage&#44; 23&#46;8&#37; with embolization&#44; and only 19&#37; required surgery&#46; Most SHH are right lobe dependent but&#44; left lobe localization could be associated &#8211; as in this case &#8211; with severity and imminent rupture&#46; We concluded that melena and abdominal pain after ERCP should warn us about the probability of severe biliary tree damage and an evolving SHH should be rule out&#46;</p></span>"
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Article information
ISSN: 00257753
Original language: English
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2023 March 2 3 5
2020 December 2 0 2
2020 June 1 0 1

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es en pt

¿Es usted profesional sanitario apto para prescribir o dispensar medicamentos?

Are you a health professional able to prescribe or dispense drugs?

Você é um profissional de saúde habilitado a prescrever ou dispensar medicamentos