Hepatic subcapsular hematoma post-ERCP: Case report and literature review

Highlights • A case of hepatic subcapsular hematoma (HSH) rupture that required surgical treatment.• Sixty one cases of HSH were described in the literature, fourteen of them ruptured.• HSH rupture has a significant increase in the mortality (21.4% × 2.2%).• Conservative treatment may be the conduct for cases with non-ruptured hematomas.• HSH rupture required surgical intervention in 78.6% of cases.


Introduction
Endoscopic retrograde cholangiopancreatography (ERCP) is today one of the most commonly performed minimally invasive procedures for the diagnosis and treatment of biliary and pancreatic diseases. Although it is a safe method, ERCP has the highest incidence of complications among upper gastrointestinal endoscopic procedures [1,2], with complication rates ranging from 2.5%-8% when performed by experienced professionals [3][4][5].
Exclusion criteria was: articles that did not have at least an abstract available in one of the following languages: Italian, French, English and Portuguese. All articles were reviewed and data on cases with HSH rupture were analyzed separately.
The data was collected by two different authors, individually, and then analyzed, in case of any disagreement another author reviewed the original paper to minimize any error.
Of the initial 70 results, nine were excluded due to not being related to the research, 2 were excluded due to language and finally 5 were excluded due to not have at least an abstract available (Chart 1).

Case report
A 25-year-old female teacher, married, native to Argentina, with no comorbidities, BMI of 24, was admitted to with jaundice to the emergency department (Bilirubin 11.2 mg/dL), with secondary choledocholithiasis diagnosed by ultrasound (US) imaging. Abdominal US showed a normal-looking liver, dilated intra and extrahepatic biliary system, with 1.3 cm bile duct and 1.0 cm calculus inside, and ERCP was indicated for treatment. The procedure was successful, and calculus was removed with the help of guide wire and papillotomy, without complications. The gallbladder did not contrast during the exam.
The patient returned to the ward hemodynamically stable and asymptomatic. After 8 h of ERCP, she experienced sudden abdominal pain and pallor, laboratory tests and abdominal radiography showed significant gastric distension (Fig. 1) and raised the hypothesis of blocked duodenal perforation, without pneumoperitoneum or complicated acute cholecystitis.
Antibiotic therapy was initiated with ciprofloxacin 400 mg every 12 h and metronidazole 500 mg every 8 h, and a CT scan of the abdomen was performed and showed subcapsular hematoma of about 15 cm in diameter, affecting liver segments VI, VII and VIII, with air and a small amount of perihepatic free fluid (Fig. 2). At this time, the patient presented with diffuse peritonitis on physical examination, and exploratory laparotomy was indicated.
Intraoperatively, a minimal amount of hemoperitoneum, a gallbladder with thick and delaminated walls, and subcapsular hematoma affecting the right lobe of the liver with oozing bleeding    in segment VI were identified (Fig. 3). Patient was hemodynamically stable with 8.0 mg/dL hemoglobin (HB). Cholecystectomy and electrocautery hemostasis were performed in active bleeding, with apparent good final appearance, as well as a methylene blue test which ruled out duodenal perforation and cavity drainage. Postoperatively, after receiving 03 units of packed red blood cells, she maintained hemodynamic stability and was submitted to arteriography -in an attempt to identify the source of bleeding -with no signs of extravasation (Fig. 4).
On the fourth postoperative day (PO), she evolved with hemodynamic instability and 1500 mL of bloody outflow through the drain, and a new surgical approach was indicated. During the intraoperative period, moderate hemoperitoneum, subcapsular hematoma affecting the entire enlarged hepatic parenchyma, and hepatic bleeding in a laceration pattern were observed. Patient received 05 units of packed red blood cells and was submitted to argon-based hemostasis and tamponade with six compresses.
She remained intubated with ARDS (acute respiratory distress syndrome), maintaining a PaO2/Fio2 ratio of 60. Abdominal drainage was serosanguineous with an outflow rate of around 40 mL. After ventilatory improvement, a new laparotomy was performed, and compresses were removed. The liver was bruised on its entire surface, with no active bleeding, and enlarged (but smaller than in the previous approach). She was extubated on the 13th postoperative day and was discharged from the Intensive Care Unit (ICU) the following day, using antibiotics and pharmacologic venous thromboembolism prophylaxis.
In the ward, the patient had some isolated fever peaks, with no defined source, and maintained antibiotic therapy with ciprofloxacin and metronidazole. On the 20th postoperative day, the patient was asymptomatic, with normal leukogram and sustained hemoglobin levels (Table 1). She underwent control a CT scan (Fig. 5) on the 22nd postoperative day, which still showed hepatic hematoma, without free fluid, and with no sings of thrombosis. The abdominal drain was removed, and the hospital discharge was scheduled to the following day. At night, the patient was asymptomatic in the ward when she experienced sudden dyspnea and died. At necropsy, the findings were pulmonary embolism and venous thrombosis in the pelvic plexus.

Discussion
ERCP is an endoscopic procedure commonly performed since its introduction in 1968 [17] with established therapeutic and diagnostic utility. Its main indications are choledocholithiasis, biliary malignancies and benign or malignant pancreatic disorders [17][18][19].
The incidence of this complication may be underestimated, since most patients have no symptoms and post-ERCP monitoring is uncommon [27,28]. The first case was described in 2000 by Ortega et al. [29] and since then only a few isolated cases have been reported, including four (7.5%) death outcomes among them, demonstrating the potential severity of this condition.
The etiology of these hematomas is still unclear, and two hypotheses have been raised. The first one suggests that liver damage is secondary to the traction force exerted by the biliary duct extractor balloon when trying to remove a retained calculus. This force would cause the rupture of biliary vessels and branches, with subsequent bleeding [11,30]. The second hypothesis, more commonly reported in the literature, suggests that the guidewire -commonly used to cannulate the common bile duct -would perforate it [26,27,[31][32][33][34], thus damaging the juxtaposed hepatic parenchyma, causing rupture of small intrahepatic vessels. Blood filtration through the hepatic parenchyma, which follow a centrifugal pattern and the presence of a solid capsule would justify the presence of air in the hematoma and thus the pathophysiology. The high frequency of infection would be justified by the use of a guide wire without sterilization [35].
In the literature review conducted in this study, of the 61 cases analyzed, 49 reported the use of guidewire in the procedure (80.3%), while 12 of them made no mention of its use or not (19.7%).
The onset of these symptoms, associated with subsequent or immediate hypotension, is suggestive of the presence of HSH. Their manifestation may occur from hours to days after the procedure [5,37] Table 3).
The most predominant diagnostic methods for HSH are CT (91.4%) and US (22.4%). In the reported case, the patient experi- enced abdominal pain, the most frequently described symptom, and anemia 8 h after ERCP, with abdominal CT. By analyzing only the subgroup of patients who had HSH rupture, we detected a significant increase in the mortality rate compared to non-ruptured (21.4% × 2.2%), even though the rupture subgroup was only 23.7% of the total number of cases reported in the literature. We also detected that patients with rupture required some type of intervention, of which 78.6% required surgery ( Table 3).
The is a predominance HSH in right the lobe (87.3%) with 5.5% of the cases affecting both lobes; we also perform a statistic analyze, using Fisher's exact test, and no associations between death and the affected liver lobe side (p = 0.256) were verified.
Treatment should be customized on a case-by-case basis, but antibiotic therapy is always recommended due to the high risk of infection [12,26]. Hemodynamically stable patients with limited, non-compressive superficial hematoma can be managed conservatively [12]. Glisson's capsule of the liver maintains hematoma stability and limits bleeding. In this approach, patient management consists of intravenous fluid infusion and replacement of blood derivatives, serial monitoring of hemoglobin concentration, serial hepatic function tests, repeated physical examination, rest and intensive care unit observation [3,26,29,38].
In addition, monitoring hematoma progression with imaging such as CT and US is the optimal approach. Whenever there is hemodynamic instability with active bleeding and contrast extravasation, immediate surgical or radiological approach should be considered [36].
Surgical treatment should be considered when patient's general conditions becomes deteriorated, when there is hemodynamic instability, signs of peritoneal irritation, infected hematoma, findings of abdominal free fluid on CT [4] and complications, such as hematoma rupture [35,[39][40][41]. In this case, the procedure consists of hematoma drainage, hemostasis with electrocauterization or hemostatic devices -if possible -and follow-up with imaging exams.
Should active bleeding and hemodynamic instability insue, it is reported in the literature that arteriography with bleeding source embolization has been used to control bleeding with satisfactory results [11,26,28,30]. Embolization by percutaneous angiography of a branch of the hepatic artery also proved to be an effective nonsurgical treatment option [41].

Conclusion
Hepatic subcapsular hematoma is a potentially fatal post-ERCP complication and should be considered as differential diagnosis of symptomatic post-procedure cases.

Declaration of Competing Interest
No conflicts of interest relevant to this article.

Sources of funding
At our own expenses.

Ethical Approval
Ethics approval: Santa Casa de São Paulo Ethics and Research Committee in Reference number: 0897129.0.0000.5479.

Consent
Written informed consent was not obtained from the patient. The head of our medical team has taken responsibility that exhaustive attempts have been made to contact the family and that the paper has been sufficiently anonymised not to cause harm to the patient or their family. A copy of a signed document stating this is available for review by the Editor-in-Chief of this journal on request.

Registration of Research Studies
Case reports that are not first-in-man study already approved in Ethics Committee.

Provenance and peer review
Not commissioned, externally peer-reviewed.