Melena after endoscopic retrograde cholangiopancreatography: A warning sign of an impending subcapsular hepatic hematoma

Montoya Rojo, José Obeth; Amezcua Gutiérrez, Marcos Antonio; Castañón-González, Jorge Alberto

doi:10.1016/j.medcli.2019.04.014

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Among ERCP complications, subcapsular hepatic hematoma (SHH) is rare and life threatening complication that requires high level of suspicious for diagnosis. A recent review by Zappa et al., reports that sudden abdominal pain (91%), hypotension (39.1%) and anemia (39.1%) after ERCP should guide to the diagnosis; other signs and symptoms include fever (21.7%) and peritonism (13%).<a class="elsevierStyleCrossRef" href="#bib0025">1</a> This varied clinical presentation can be misleading, delaying diagnosis and prompt resolution. Herein we describe a case in which melena due to significant hemobilia was the preceding sign of an evolving SHH after ERCP.A 25-years old female with a history of abdominal pain, fever and jaundice underwent an urgent ERCP and sphincterotomy for choledocholithiasis. 24h post-ERCP she complained of mild abdominal pain, melena and palpitations. An evaluation confirmed melena and a hemoglobin drop of 3g/dL. An esophago-gastro-duodenoscopy ruled out active peptic disease; a big clot was seen in the major duodenal papilla, therefore sclerotherapy with epinephrine was done and 48h after procedure, intensive care unit (ICU) evaluation was requested; the patient was on shock and high dose vasopressors, laboratory test reported a total hemoglobin drop of 6g/dL, hematocrit 18%, metabolic acidosis and hyperlactatemia. Abdominal ultrasound with FAST protocol (Focused Assessment with Sonography in Trauma) showed 100% inferior vena cava collapsibility, free fluid in the hepatorenal, perisplenic and suprapubic recesses; also with an intracapsular anechoic liver image suggestive of a left lobe SHH, which was confirmed by an abdominal computed tomography scan. An exploratory laparotomy was performed. Surgery findings were a massive 1500mL hemoperitoneum due to a left hepatic lobe ruptured hematoma. After abdominal packing and closure, she was admitted to the ICU on shock. Multiple red blood packages and fresh frozen plasma were transfused. Despite aggressive reanimation in the intensive care, bleeding persisted and she died on hypovolemic shock after a second surgery.Inadvertent guide wire perforation of the biliary tree during ERCP should be suspected in any patient with abdominal pain and anemia after the procedure, because an early diagnosis carries low death rates. To our knowledge melena has not been reported as a companion of SHH, therefore we will like to include it as a sign of severe biliary tree damage; because it reflects significant hemobilia and therefore an impending SHH should be ruled out.Recently, Alzubaidi et al.,<a class="elsevierStyleCrossRef" href="#bib0030">2</a> reported a left hepatic lobe SHH as in our case but almost all reported are on right lobe. Perforation of the biliary tree and small hepatic vessels injury with the metallic guide wire during the procedure occurred in around 95% of the reported cases.<a class="elsevierStyleCrossRefs" href="#bib0025">1–4</a>Although SHH it is considered a life threatening condition, low death rates are reported associated to an early diagnosis and treatment by embolization. Zizzo et al.,<a class="elsevierStyleCrossRef" href="#bib0040">4</a> reported 47.6% of patients treated conservatively, 23.8% with percutaneous drainage, 23.8% with embolization, and only 19% required surgery. Most SHH are right lobe dependent but, left lobe localization could be associated – as in this case – with severity and imminent rupture. 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." 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Hernando-Alonso" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Case Rep Clin Med" "fecha" => "2014" "volumen" => "3" "paginaInicial" => "161" "paginaFinal" => "166" ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0040" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Subcapsular hepatic hematoma after endoscopic retrograde cholangio-pancreatography: a case report and review of literature" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "M. Zizzo" 1 => "A. Lanaia" 2 => "I. Barbieri" 3 => "C. Zaghi" 4 => "S. Bonilauri" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:4 [ "tituloSerie" => "Medicine (Baltimore)" "fecha" => "2015" "volumen" => "94" "paginaInicial" => "e1041" ] ] ] ] ] ] ] ] ] ] "agradecimientos" => array:1 [ 0 => array:4 [ "identificador" => "xack463980" "titulo" => "Acknowledgements" "texto" => "The authors would like to thank Hospital Juárez de México for the facilities that it provided to conduct this article." 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