Subcapsular hepatic haematoma of the right lobe following endoscopic retrograde cholangiopancreatography: Case report and literature review

Sub capsular hepatic haematoma is a rare complication after endoscopic retrograde cholangiopancreatography(ERCP). Exact pathological mechanism is still unclear and few reports are nowadays available in literature. We report the case of a 58-year-old woman with recurrent episodes of upper abdominal pain, nausea and vomiting. On the basis of laboratory exams, abdomen ultrasound and magnetic resonance imaging she was diagnosed with a common bile duct stone. Endoscopic biliary sphincterotomy was performed. On the following day the patient complaint severe abdominal pain with rebound and hemodynamic instability. A computed tomography scan reveal a 14 cm × 6 cm × 19 cm subcapsular hepatic haematoma on the right lobe that was successfully managed via percutaneous embolization. Sub capsular liver haematoma is a rare life threatening complication after ERCP that should be managed according to patients' haemodynamic and clinic.     

Subcapsular Hepatic Hematoma After Endoscopic Retrograde Cholangiopancreatography: A Case Report and Review of Literature

Endoscopic retrograde cholangiopancreatography (ERCP) is one of the most frequently performed procedures for the diagnosis and treatment of biliary-pancreatic diseases. ERCP-related complications total around 2.5% to 8%, with a mortality rate ranging from 0.5% to 1%. An exceptional ERCP complication is subcapsular hepatic hematoma, and few cases are reported worldwide.We present the case of a 52-year-old woman with a history of recurring upper abdominal pain and a clinical and ultrasonographic diagnosis of obstructive jaundice due to common bile duct stones. After 2 difficult endoscopic biliary procedures, common bile duct stones clearance was obtained. Post-ERCP course was symptomatic with upper abdominal pain and anemization with hemodynamic instability.CT scan demonstrated a 15 cm × 11 cm subcapsular hepatic hematoma filled with air and liquid on the surface of the right hepatic lobe. The patient was successfully treated with the embolization of a small branch of right hepatic artery angiographically identified as the cause of bleeding.Subcapsular hepatic hematoma after ERCP is a rare complication that must be taken into account in the differential diagnosis of symptomatic cases after ERCP. Its diagnosis is based on clinical and laboratory data and especially on imaging (ultrasound, CT, or MRI). Treatment is often conservative but, in some cases, embolization or percutaneous drainage or surgery may be necessary.     

Subcapsular liver hematoma after endoscopic retrograde cholangiopancreatography in a liver transplant recipient: Case Report

Endoscopic Retrograde Cholangiopancreatography (ERCP) is commonly performed in patients after liver transplantation. The most common indications for ERCP include treatment of bile leaks and anastomotic and nonanastomotic biliary strictures. In this report we describe an unusual complication of ERCP in a liver transplant recipient with a bile leak two months after orthotopic liver transplantation (OLT). After confirming a bile leak, a hydrophilic guide wire was placed in the intrahepatic duct, an endoscopic sphincterotomy was performed, and a biliary plastic stent was successfully placed over the wire across the bile leak. Within the following 24 hours the patient developed a sharp right-sided upper quadrant pain and a drop in his hemoglobin level. An abdominal CT scan demonstrated a subcapsular hepatic hematoma that was successfully managed conservatively.     

The role of endoscopic treatment in postoperative bile leaks

BACKGROUND/AIMS: Bile leak is among the most common and serious complications of biliary tract surgery. The aim of this non-randomized study was to evaluate the role of endoscopic intervention as an accepted treatment for this complication. METHODOLOGY: An endoscopic retrograde cholangiopancreatography (ERCP) database was reviewed retrospectively to identify all cases of bile leak related to cholecystectomy (laparoscopic or open). Patients' records and endoscopy reports were reviewed. Moreover, structured telephone interviews were conducted to collect data. RESULTS: Twenty-four patients, 4 males and 20 females, with a median age of 54 (range 28-76 years) with suspected postcholecystectomy bile leaks were referred for ERCP performed 3-73 days after operation (mean 9.5 days). All but one case had high-grade bile-like liquid outflowing from the original drainage tubes or the fistulous tract of T-tube. One patient presented with bilious ascites, 17 patients had sudden or gradual abdominal pain, 3 jaundice, 2 abdominal pain with fever, and 1 nausea and vomiting. ERCP was successful in all cases, and revealed leakage from the cystic stump in 10 cases, from a common bile duct (CBD) defect in 6, from a common hepatic duct defect in 3, from the gallbladder bed in 2, from a T-tube track in 1, and complete CBD transection in 2 patients. Seventeen patients were successfully treated by endoscopic sphincterotomy (ES) plus endoprosthesis, 3 by stent placement without sphincterotomy, 2 with complete transection by proximal hepaticojejunostomy, and 2 patients with leakage from the cystic stump and a CBD defect were operated after unsuccessful endoscopic intervention. CONCLUSIONS: ERCP is recommended as a safe and efficacious intervention to detect and treat postoperative bile leaks. ES plus endoprosthesis is effective for the treatment of bile leakage. Endoscopic stenting without sphincterotomy may be offered as a primary option in young patients with postoperative bile leaks.     

Duplication of the common bile duct manifesting as recurrent pyogenic cholangitis: A case report

BACKGROUNDDuplication of the extrahepatic bile duct (DCBD) is an extremely rare congenital anomaly of the biliary system. There are five types of DCBD according to the latest classification. Among them, Type V is characterized by single drainage of the extrahepatic bile ducts. Reports on DCBD Type V are scarce.CASE SUMMARYA 77-year-old woman presented with recurrent epigastric pain but without fever or chills. Computed tomography revealed a dilated common bile duct (CBD) that harboured multiple choledocholithiasis. Endoscopic retrograde cholangio-pancreatography (ERCP) was performed, and the stones were extracted using a Dormia basket. She was discharged without any complications; however, she visited the emergency department a day after she was discharged due to epigastric pain and fever. Laboratory findings were suggestive of cholestasis. After urgent ERCP for stone removal, magnetic resonance cholangiopancrea-tography was performed to evaluate remnant choledocholithiasis. Magnetic resonance cholangiopancreatography revealed a DCBD Type Va and remnant choledocholithiasis in the right CBD. Both CBDs were accessed, and the stones were cleared successfully during a subsequent ERCP.CONCLUSIONIn this article, we report an extremely rare case of DCBD manifesting as recurrent pyogenic cholangitis. This case highlights the importance of recognizing DCBD because stones in the unrecognized bile duct could make the patient’s prognosis critical.     

ENDOSCOPIC NASOBILIARY GALLBLADDER DRAINAGE AFTER ENDOSCOPIC SPHINCTEROTOMY IN PATIENTS WITH ACUTE CHOLECYSTITIS AND CHOLEDOCHOLITHIASIS

A 77‐year‐old man was admitted for the treatment of obstructive jaundice and right hypochondralgia with high fever. An abdominal computed tomography revealed common bile duct stones and acute cholecystitis with gallstones. Magnetic resonance cholangiopancreatography revealed stones in the common bile duct. Endoscopic retrograde cholangiopancreatography also revealed stones in the common bile duct, and immediately endoscopic sphincterotomy was performed. After lithotripsy of the bile duct, continuous endoscopic nasogallbladder drainage was performed successfully. There was severe pus in the gallbladder. Next day, the patient was doing well; there was no pain and fever was down.     

A case of choledocholithiasis treated by parallel cannulation along with PTGBD rendezvous

We herewith describe a case of choledocholithiasis, with large duodenal diverticula, endoscopically treated by the parallel cannulation method alongside the extended percutaneous transhepatic gallbladder drainage (PTGBD) tube. An 81-year-old man was admitted to hospital with complaint of abdominal pain and high-grade fever. The patient was treated by PTGBD and was referred to our institution. Endoscopic retrograde cholangiography (ERC) showed a wildly winding lower bile duct, so that we could not approach the bile duct stone at that time. Next, we extended a PTGBD tube into the duodenal lumen and stretched the lower bile duct straight. Then, the bile stone was successfully moved out through ampulla without any complication.     

Adenomyoma of the common hepatic duct

BackgroundAdenomyoma occurs most commonly in the fundus of the gallbladder, seldom in other parts of the gallbladder and rarely in the extrahepatic biliary tree, where most lesions are localised to the common bile duct or papilla of Vater. Adenomyoma of the common hepatic duct is extremely rare. To the best of our knowledge, only three cases have been reported so far.Case outlineA 51-year-old woman was admitted with a three month history of attacks of right upper abdominal pain, nausea, vomiting and fever. Laboratory data, ultrasonography, ERCP and CT confirmed slight cholestasis and proximal bile duct dilatation due to a tumour within the common hepatic duct. Cholecystectomy was performed with excision of the suprapancreatic common bile duct including the convergence of the hepatic ducts plus lymphadenectomy and Roux-en-Y hepaticojejunostomy. Frozen section histology showed the benign nature of the lesion and a tumour-free resection line. Final histology showed adenomyoma. The patient has remained symptomfree for more than 30 months.DiscussionAlthough adenomyoma is a benign lesion and the surgical strategy has not been established, complete excision with frozen section is recommended to exclude small malignant foci and local recurrence as well as to avoid surgical over-treatment.     

Is ERCP really necessary in case of suspected spontaneous passage of bile duct stones？

AIM： To investigate the usefulness of magnetic resonance cholangiopancreatography （MRCP） and the need for endoscopic retrograde cholangiopancreatography （ERCP） in cases of suspected spontaneous passage of stones into the common bile duct.
METHODS： Thirty-six patients with gallbladder stones were clinically suspected of spontaneous passage of stones into the common bile duct because they presented with clinical symptoms such as abdominal pain and fever, and showed signs of inflammatory reaction and marked rise of hepatobiliary enzymes. These symptoms resolved and they showed normalized values of blood biochemical parameters after conservative treatment without evidence of stones in the common bile duct on MRCP. All these patients were subjected to ERCP within 3 d of MRCP to check for the presence of stones.
RESULTS： No stones were detected by ERCP in any patient, confirming the results of MRCP.
CONCLUSION： When clinical symptoms improve, blood biochemical parameters have normalized, and MRCP shows there are no stones in the common bile duct, it can be considered the stone has spontaneously passed and thus ERCP is not necessary.     

经内镜鼻胆管引流术在腹腔镜胆管探查中的作用

目的：应用经内镜鼻胆管引流术(ENBD)作为腹腔镜胆管探查术(LCBDE)胆管引流方式，探讨其应用价值。方法：对拟行腹腔镜下胆管探查的患者术前进行ENBD，后经胆总管探查切口应用液电碎石、胆道镜取石，将肝内外胆管结石取净，保留鼻胆管于胆管内，将胆总管探查切口一期缝合，常规放置腹腔引流管。术后经鼻胆管造影，肝内外胆管无残余结石，无胆漏，择期拔除腹腔引流管及鼻胆管。结果：共43例患者术前行ENBD，平均6．1d后行LCBDE。36例(83.7％)患者成功进行LCBDE，胆管探查切口一期缝合。术后经鼻胆管造影，发现1例(2．6％)术中胆道镜漏诊--小结石，经内镜取石后痊愈；无胆管狭窄及胆漏等并发症发生。另有7例患者(18．6％)中转开腹手术，其中2例保留鼻胆管，胆管切口行一期缝合，术后顺利拔除鼻胆管。38例患者(88．4％)均成功应用：ENBD进行胆管引流，平均3．2d拔除腹腔引流管，6.7d拔除鼻胆管，无相关并发症发生。结论：ENBD作为LCBDE胆管引流，是安全有效的方式，且术后引流时间短，并发症少，可充分发挥出腹腔镜治疗胆管结石微创的优势。     

Endoscopic retrograde cholangiopancreatography in elderly patients.

BACKGROUND: the presentation of common bile duct disease, value of investigations and treatment outcome in elderly patients undergoing endoscopic retrograde cholangiopancreatography (ERCP) were assessed. METHODOLOGY: the clinical presentation, liver function tests, full blood counts, abdominal ultrasound and ERCP results were assessed retrospectively in 101 patients (59 women, 42 men; mean age 83 years, range 75-100) sequentially investigated for possible common bile duct disease. RESULTS: 59 patients had common bile duct gallstones, 35 had malignant biliary obstruction (13 with co-existing common bile duct stones) and seven had other outcomes. In the malignant-alone group 68% of those who had jaundice presented painlessly compared with 24% in the gallstones-alone group; 49% of the gallstones-alone group had pain compared with 28% of the malignant group. In the gallstones-alone group 43% had atypical presentations (non-specific symptoms or painless jaundice). Non-specific symptoms were found in 19% of the gallstones-alone group but in only 5% of the malignant group. Of the patients who had common bile duct stones, 18% had pancreatic or biliary malignancy. The co-existence of gallstones and malignancy was emphasized by eight patients in whom the clinical and ultrasound diagnosis was of common bile duct stones but malignancy was detected by ERCP. The sensitivity of ultrasound was 86% for detecting dilated common bile ducts was 86%, but only 69% for diagnosing gallstones within the common bile duct and 67% for diagnosing pancreatic masses. Ultrasound and ERCP were in agreement in 60 patients (60%). Endoscopic clearance of common bile duct gallstones was successful in 53 of 54 attempts (98%). Palliative ERCP treatment was performed in 30 patients who had malignant biliary obstruction and was successful in 22 (73%); in a further four patients (13%) an endoprothesis was successfully inserted percutaneously. The commonest complication of ERCP was cholangitis (four patients); pancreatitis and biliary perforation occurred in one patient each. Twenty-two patients (63%) who had malignancy died during follow-up, the mean survival being 11.3 weeks (range 3 days-2 years). Carcinoma of the ampulla was associated with a relatively good prognosis (three patients survived 18 months or more). CONCLUSION: in elderly patients, common bile duct stones often present atypically and co-existence with malignancy is not unusual; ampullary carcinoma has a relatively good prognosis and ERCP is a safe and effective procedure in the management of biliary obstruction.     

25例肝包虫囊肿破入胆道的诊治体会

目的探讨肝包虫囊肿破入胆道的诊断及治疗方式。方法回顾分析我院2001年～2011年行手术治疗的25例肝包虫囊肿破入胆道患者的临床表现、实验室检验、影像学检查、手术方式及治疗效果。结果超声、CT、磁共振胰胆管成像(MRCP)及内镜逆行胰胆管造影(ERCP)对于肝包虫囊肿破入胆道均具有良好的诊断价值,其中ERCP诊断价值最高,确诊率可达100%。25例患者中22例手术方式为胆囊切除、胆总管探查、T管引流+肝包虫残腔引流,其余3例行胆囊切除、胆总管探查、T管引流+肝包虫病灶根治性切除。所有患者均痊愈出院。结论超声因普及易行,应作为诊断肝包虫囊肿破入胆道的首选辅助检查,MRCP检查具有诊断准确率高和无创等优点,ERCP则对肝包虫囊肿破入胆道诊断率最高。胆囊切除、胆总管探查、T管引流+肝包虫残腔引流应作为肝包虫囊肿破入胆道首选手术方式,对于部分复杂病例可行胆囊切除、胆总管探查、T管引流+肝包虫病灶根治性切除,效果良好。     

Hemobilia and liver flukes in a patient from Thailand

A patient from Southeast Asia presented with abdominal pain, fever, jaundice, and upper gastrointestinal bleeding of unknown origin. Opisthorchis viverrini eggs were found in the stool and multiple hepatic filling defects were noted on liver scan and sonogram. Endoscopic retrograde cholangiopancreatography revealed cholelithiasis and crescent-like filling defects in the biliary system. At surgery, the gallbladder was filled with clotted blood and pigmented stones. During T-tube drainage of the common bile duct, small elliptical flukes (4 X 3 mm) identified as O. viverrini were recovered. Despite adequate biliary drainage, the patient continued to have high fevers. On the 53rd postoperative day, a larger fluke (2.8 X 0.8 cm) identified as a Fasciola hepatica migrated down the T-tube. Institution of therapy with bithional resulted in complete clinical resolution within 3 wk. Six years later the patient returned with fever, jaundice, and right upper quadrant pain. Two large pigmented stones were found in the common bile duct and were removed after endoscopic sphincterotomy. The stones had developed even though there was no evidence of recurrent helminthic infection.     

Endoscopic management of bile leaks after blunt abdominal trauma

Background and Study Aims:  Endoscopic retrograde cholangiopancreaticography (ERCP) has been found to be useful for the diagnosis and treatment of post-traumatic bile leaks, but data on outcome after therapeutic ERCP is limited. We performed a prospective study on evaluation of ERCP for diagnosis and treatment of bile leaks following blunt abdominal trauma.
Patients and Methods:  Ten patients of bile leaks following blunt abdominal trauma were evaluated for modes of injury, clinical presentations, investigations, ERCP findings, modes of therapy and outcome. The time interval between trauma and ERCP, ERCP and healing of bile leak and complications of ERCP were also recorded.
Results:  Ten patients (age 21.9 ± 14.5 years, 6 males) presented 24.6 ± 17.1 days following trauma. The modes of injury were motor vehicle accident ( n  = 6), and fall from height ( n  = 4). The ERCP revealed bile leak from the right hepatic duct ( n  = 7), both right and left hepatic ducts ( n  = 1), mid-common bile duct ( n  = 1), and peripheral branches of right hepatic duct ( n  = 1). Procedures for ERCP included endoscopic sphincterotomy (ES) with stenting in nine patients and ES with nasobiliary drainage in one patient. Bile leak resolved in all the patients in 8.5 ± 8.2 days. Biliary stents and the nasobiliary drain were removed after 36.4 ± 16.2 days of their insertion and all the patients remain asymptomatic for follow up of 33 ± 20.8 months.
Conclusions:  Therapeutic ERCP procedures like endoscopic sphincterotomy with stenting or nasobiliary drainage are effective in management of bile leaks following blunt abdominal trauma.     

ERCP在不明原因肝外阻塞性黄疸的临床应用

目的探讨内镜逆行胰胆管造影（ERCP）在经常规检查不明原因肝外阻塞性黄疸的临床应用价值。方法收集经B超、cT和,或MRCP检查诊断不明原因胆胰疾病或肝外胆管梗阻病人45例,男28例,女17例,年龄21—80岁,均行ERCP术。结果45例病人行ERCP术,其中42例诊断为胆道微结石（Biliary microlithiasis,BML）,42例均行乳头扩张术／EST4-胆道取石术;3例为胆总管下端炎性狭窄而行胆道内支架植入术;1例ERCP取石术后并发轻症胰腺炎,经内科保守治疗后痊愈,l例因腹痛再发行胆囊切除术,其余患者经ERCP治疗后腹痛、黄疸均缓解。结论BML是不明原因肝外阻塞性黄疸的主要原因,ERCP是不明原因肝外阻塞性黄疸安全、有效的诊断及治疗手段。     

A rare etiology of post-endoscopic retrograde cholangiopancreatography pneumoperitoneum

Major complications of endoscopic retrograde cholangiopancreatography （ERCP） include pancreatitis, hemorrhage, cholangitis, and duodenal perforation. The occurrence of free air in the peritoneal cavity post- ERCP is a rare event （〈 1%）, which is usually the result of duodenal or ductal perforation related to therapeutic ERCP with sphincterotomy. We describe for the first time a different aetiology of pneumoperitoneum, in an 84-year-old woman with pancreatic cancer and a large hepatic metastasis, after ERCP with common bile duct stent deployment. Our patient developed, pneumoperitoneum due to air leakage from rupture of intrahepatic bile ducts and Glisson’s capsule in the area of a peripheral large hepatic metastasis. The potential mechanism underlying this complication might be post- ERCP pneumobilia and increased pressure of intrahepatic bile ducts leading to rupture of intrahepatic bile ducts in the liver metastatic mass owing to neoplastic tissue friability. This case indicates the need for close clinical and radiological observation of patients with hepatic masses （primary or metastatic） subjected to ERCP. In such patients, avoidance of excessive air insufflation during ERCP and/or placement of a nasogastric tube for bowel decompression immediately after ERCP might be a reasonable strategy to prevent such unusual complications.     

经内镜逆行胰胆管造影在治疗妊娠合并急性胆源性胰腺炎中的作用

目的 探讨ERCP在妊娠合并急性胆源性胰腺炎(ABP)中的治疗作用.方法 选择2002年1月至2007年1月共收治的24例妊娠合并ABP患者,其中轻症14例,重症10例.在内科治疗的基础上,在无x线透视下急诊行ERCP.先行内镜鼻胆管引流术(ENBD)以减压、减黄,待患者病情稳定后,对明确有胆总管结石的患者,若早、中期妊娠则行内镜胆道塑料内支架引流术(ERBD),若晚期妊娠则在终止妊娠后再次行ERCP取石.结果 24例患者均顺利完成急诊ERCP+ENBD,有4例见壶腹部结石嵌顿,用针型刀剖开十二指肠乳头,取出结石;15例明确有胆总管结石,其中5例行ERBD,10例终止妊娠后再次行ERCP取石成功.无孕妇死亡,无转外科手术治疗,均治愈出院.重症患者中有2例胎儿死亡.结论　对妊娠合并ABP患者急诊行ERCP+ENBD,病情稳定后行ERBD或再次行ERCP取石是安全、有效的.     

经内镜诊治肝移植术后胆道远期并发症

目的：探讨经内镜逆行胰胆管造影(ERCP)在诊断和治疗肝移植患者胆道远期并发症中的应用。方法：肝移植术后出现胆道远期并发症患者6例，共行ERCP 12次，根据患者的情况进行扩张、内镜下乳头切开取石、内支架置入等治疗。结果：1例胆总管结石行乳头切开后取石成功，1例胆道狭窄在胆道扩张后胆道梗阻症状解除，4例胆道狭窄合并胆总管结石的狭窄近端结石经乳头切开取出，狭窄远端结石行胆道扩张、内支架置入等治疗后取出。所有患者经治疗后胆红素、碱性磷酸酶等酶学指标均有不同程度的下降，无严重并发症发生。结论：ERCP是诊断和治疗肝移植患者胆道远期并发症安全、有效的手段。     

Diagnostic value of magnetic resonance cholangiopancreatography for clinically suspicious spontaneous passage of bile duct stones

Background and Aim: We investigated the usefulness of magnetic resonance cholangiopancreatography (MRCP) and the need for endoscopic retrograde cholangiopancreatography (ERCP) in patients with clinically suspicious spontaneous passage of bile duct stones. Methods: The study population consisted of 113 patients suspected of having common duct bile stones. Of them, 50 patients were clinically suspected of spontaneous passage of bile duct stones based on the presence of gallbladder stones on ultrasound examination or a history of common bile duct stones after cholecystectomy, clinical symptoms including abdominal pain and fever associated with inflammatory reaction and marked rise of hepatobiliary enzymes which resolved or normalized after conservative treatment without evidence of stones in the common bile duct on MRCP. These 50 patients were prospectively followed up for a median of 10.2 months. Results: All patients except for one had had no symptoms related to cholangitis. Only one patient received ERCP due to recurrence of symptoms after 6 months. Conclusion: When clinical symptoms improve, hematological parameters normalize, and MRCP indicates that there are no stones in the common bile duct, it can be considered that the stones have passed naturally.     

Intrahepatic subcapsular biloma after endoscopic retrograde cholangiopancreatography treated by endoscopic biliary drainage

Several major complications from endoscopic retrograde cholangiopancreatography (ERCP), including pancreatitis, cholangitis, and hemorrhage have been discussed in detail; however, a few uncommon but severe complications have been reported. We encountered an unusual case of post-ERCP intrahepatic subcapsular biloma. An 89-year-old woman with a 25-mm mass located at the hepatic hilum, suggestive of cholangiocarcinoma, underwent ERCP which demonstrated complete stricture of the common hepatic duct. Subsequently, two plastic stents were placed from the common bile duct to the right and left intrahepatic branches. On day 3, serum inflammatory markers were elevated and computed tomography revealed a large subcapsular fusiform fluid collection in the right liver, consistent with biloma. On day 6, the biloma ruptured and 500 ml of biliary ascites were removed. On day 8, endoscopic nasobiliary drainage via the right intrahepatic branch was performed because of recurrence of biliary ascites. After the procedure, 150 ml of bile was collected through the drain every day and no ascites recurred. We believe that minor injury to the right intrahepatic bile duct due to guidewire manipulation caused the biloma. Biloma may become apparent several days after ERCP, and endoscopic biliary drainage placement adjacent to the bile duct rupture site can stop bile leakage.