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From question on page 854
Hepatic haematoma after endoscopic retrograde cholangiopancreatography (ERCP) is a rare but potentially life‐threatening complication. In this case, the abdominal CT scan demonstrated the biliary stents in good position with a reduction in intrahepatic biliary ductal dilatation. A large subcapsular haematoma at the lateral margin of the right hepatic lobe measuring 16×15×7 cm in maximal dimensions was seen. The patient was admitted and managed conservatively without the need for transfusion.
Four such cases have been described previously.1,2,3,4 One of these cases occurred after diagnostic ERCP in a patient with underlying coagulopathy. Coexistence of splenic avulsion and left hepatic lobe laceration suggested bowing of the duodenoscope while passing through the stomach or using the long position during cannulation as possible mechanisms of trauma. This patient was managed with emergency laparotomy.1 The other cases occurred after therapeutic ERCP of extrahepatic bile duct disease.2,3,4 In all cases, the likely mechanism of the hepatic haematoma was believed to be guidewire puncture of the liver parenchyma. All were managed non‐surgically with observation alone,3 percutaneous draining2 or selective embolisation of the hepatic artery.4
The unique features of our case include the extensive intrahepatic ductal intervention performed with balloon dilation, brush cytology and placement of a long stent, all of which could potentially rupture the intrahepatic blood vessels in addition to the guidewire itself. Furthermore, the ruptured blood vessels may have originated from the malignant mass encasing the right intrahepatic ducts. In the era of therapeutic ERCP, there may be an increase in the prevalence of this type of iatrogenic complication. When identified and treated rapidly, such patients can be conservatively managed. Selective embolisation of the hepatic artery can be performed to control refractory bleeding.