Endoscopic retrograde cholangiopancreatography (ERCP) was introduce in 1968 as a diagnostic tool. With the introduction of sphincterotomy in 1974, ERCP began its application as a therapeutic option. Biliary tree obstruction due to choledocholithiasis, and benign or malignant stenosis, are classic indications for an ERCP, as all surgeons know.
ERCP saw its use being widespread through worldwide hospitals and clinics. Although invasive, it is less invasive than surgery. However it is not free of complications, and some of these are potentially fatal. ERCP has a morbidity rate of 2,5-8%, and a mortality rate up to 1%. Pancreatitis is the most common complication, but other rarer ones can occur.
In that setting, Teresa Caroço and fellows from the Surgery C Department of "Centro Hospitalar e Universitário de Coimbra (Hospital dos Covões)" published in BMJ Case Reports a rare case of an hepatic haematoma complicating an ERCP. Procedure was uneventful, but 36h later patient was diagnosed with an hepatic haematoma. Conservative treatment with broad spectrum antibiotics was the option, with complete resolution of the lesion in a 10 months later CT scan.
Hepatic haematoma is a rare complication, with only 44 cases reported in worldwide literature. Beside rare it is potencially fatal. Pathophysiology is unclear, but probably is due to laceration with the guidewire. However, there are cases of subcapsular haematoma following a procedure without the use of a guidewire. In that setting, and according to some authors, trauma during ballon traction may be the cause. Abdominal pain is the most frequent presenting symptom, with right shoulder pain present in some cases. According to Teresa Caroço et al. since symptoms are non-specific "sudden pain after ERCP should raise concern for hepatic haematoma". Time gap from ERCP to symptoms onset goes from immediate to 15 days, but in the majority of cases symptoms begin within the first 24h. Due to non-specific symptoms a diagnosis delay up to 5 days is possible.
"... sudden pain should raise concern for hepatic haematoma, and doctors must have a low threshold of suspiction in order to make an early diagnosis."
Teresa Caroço et al.
Abdominal ultrasound, CT scan or MRI are essential for diagnosis. Treatment depends on patient's clinical status. In the presence of haemodinamic stability a conservative treatment with broad spectrum antibiotics is indicated. If haemodinamic instability exists or if conservative treatment fails, an invasive management is necessary. CT guided percutaneous drainage and embolisation is an option, and in more severe cases with rupture surgery is indicated.
There are 4 cases of death following an hepatic haematoma complicating an ERCP. That is why the authors conclude "that all surgeons must be aware of this complication and must be able to identify it promptly, ensuring a better patient outcome."
Because in Portugal many patients stay in the surgery ward after an ERCP performed in the Gastroenterology department, and are not submitted to follow-up by the performing doctor, surgeons must know all the possible complications after an ERCP. The surgeon is responsible for diagnosis and treatment of another doctor's complication. And some of them will never know about it...
Link to PubMed:
Dr. Carlos Eduardo Costa Almeida
General Surgeon