Splenic subcapsular hematoma following endoscopic retrograde cholangiopancreatography: A case report and review of literature

Abstract

BACKGROUND

Splenic injury following endoscopic retrograde cholangiopancreatography (ERCP) is a rare complication. The literature contains around 30 articles reporting various degrees of splenic injuries resulting from ERCP since the first report of splenic rupture after ERCP in 1989.

CASE SUMMARY

This report describes a case of splenic hematoma and stent displacement in a 69-year-old male patient who developed these conditions 7 days after undergoing ERCP and stenting. The patient had bile duct stenosis caused by a malignant tumor that was obstructing the bile duct. The diagnosis was confirmed by epigastric computed tomography and magnetic resonance cholangiopancreatography. The patient was successfully treated with percutaneous transhepatic cholangial drainage, endoscopic pyloric stent placement, and conservative management. The causes of splenic injury following ERCP are discussed.

CONCLUSION

ERCP has the potential to cause splenic injury. If a patient experiences symptoms such as abdominal pain, decreased blood pressure, and altered hematology after the procedure, it's important to be thoroughly investigated for postoperative bleeding and splenic injury.

Key Words: Endoscopic retrograde cholangiopancreatography, Gastroenterology, Splenic injury, Hematoma, Case report

Core Tip: There are several possible causes of abdominal pain and fever in patients who have undergone endoscopic retrograde cholangiopancreatography (ERCP). One of the potential complications that should not be overlooked is splenic injury. A clear diagnosis can be established based on laboratory and imaging examinations. It is important to closely monitor the patient's condition after ERCP and to promptly address any signs of discomfort.

INTRODUCTION

Endoscopic retrograde cholangiopancreatography (ERCP) is a frequently used diagnostic and therapeutic tool for pancreatobiliary disease[1]. Complications occur in 5%-10% of cases and may include pancreatitis, bleeding, and perforation[2]. Although rare, splenic injury has also been reported following ERCP. Our literature review found approximately 30 reported cases of splenic injury since the first case was reported in 1989[3]. Details of the first report and subsequent similar reports are shown in Table 1[3-30]. We describe a patient who developed a splenic hematoma after undergoing ERCP. The diagnosis was confirmed by objective imaging, and the condition was successfully treated using conservative methods.

Table 1 Published reports on spleen injuries worldwide following endoscopic retrograde cholangiopancreatography.

Ref.	Year	Age/gender	Comorbid conditions	Clinical manifestations	Onset after ERCP	Type of injury	Therapy
Trondsen et al[3]	1989	46/Female	Pancreatitis	ERCP, sphincterotomy	15 hours	Splenic capsular avulsion	Splenectomy
Pamudurthy et al[4]	2018	60/Female	Choledocholithiasis	ERCP, stenting	8 hours	Splenic rupture	Splenectomy
Grammatopoulos et al[5]	2014	64/Male	Obstructive jaundice, tumor	ERCP, stenting	6 hours	Splenic rupture	Splenectomy
Boustany et al[6]	2023	41/Female	Gallstone pancreatitis, cholecystectomy	ERCP, stenting	24 hours	Splenic subcapsular hematoma	Embolization
Polman et al[7]	2020	52/Male	Nil	ERCP, stenting	Immediately	Splenic laceration	Embolization
Montenovo et al[8]	2017	41/Female	Liver transplant	ERCP, sphincterotomy	8 hours	Splenic subcapsular hematoma	Splenectomy
Momani et al[9]	2018	44/Female	Sleeve gastrectomy	ERCP, sphincterotomy	A few hours	Splenic subcapsular hematoma	Conservative
Haneke et al[10]	2018	39/Male	Chronic pancreatitis	ERCP	6 days	Splenic abscess	Conservative
Lee et al[11]	2017	59/Female	Profound jaundice.	ERCP, replace stenting	4 hours	Peri-splenic hematoma	Conservative
Cebrián García et al[12]	2022	83/Male	Nil	ERCP, sphincterotomy	6 hours	Splenic rupture	Splenectomy
Lubikowski et al[13]	2020	31/Female	Hepatectomy, biliary leak	ERCP, stenting	Shortly	Splenic rupture	Splenectomy
Agarwal et al[14]	2022	63/Male	Jaundice	ERCP, sphincterotomy, stricturoplasty, stenting	4 days	Splenic hematoma	Embolization
Kingsley et al[15]	2001	54/Female	Chronic pancreatitis, hepatitis C, cirrhosis	ERCP, sent revision	24 hours	Splenic rupture	Splenectomy
Badaoui et al[16]	2002	42/Male	Cholecystolithiasis, Common bile duct dilation	ERCP	20 minutes	Splenic laceration	Conservative, surgery
Lewis et al[17]	1991	49/Female	Common bile duct stricture, pancreatic head tumor	ERCP, stenting, biopsy	9 hours	Avulsion of short gastric vessels	Splenectomy
Ong et al[18]	1991	55/Female	Common bile duct stricture, tumor	ERCP	48 hours	Intrasplenic hematoma	Splenectomy
Furman et al[19]	1993	63/Female	Common bile duct stricture	ERCP, papillotomy	Not reported	Splenic subcapsular hematoma; Splenic abscess, pancreatitis	Observation, abscess drained
Wu et al[20]	1993	57/Female	Pelvic surgery	ERCP, sphincterotomy	60 hours	Splenic capsular avulsion	Splenectomy
Lo et al[21]	1994	79/Male	Billroth I anastomosis	ERCP, papillotomy	48 hours	Splenic subcapsular hematoma	Observation,
Deist et al[22]	2003	52/Female	Prior abdominal surgery	ERCP, sphincterotomy	8 hours	Splenic rupture	Splenectomy
Zyromski et al[23]	2004	33/Female	Nil	ERCP, sphincterotomy	24 hours	Avulsion of short gastric vessels	Splenectomy
Dixon et al[24]	2004	38/Male	Chronic pancreatitis	ERCP	Immediately	Splenic capsular avulsion	Laparotomy
Cho et al[25]	2008	63/Female	Prior laparotomy	ERCP	18 hours	Splenic laceration	Splenectomy
Cortiñas Sáenz et al[26]	2010	82/Female	Cardiovascular disease	ERCP	Immediately	Splenic rupture	Splenectomy
Gaffney et al[27]	2012	48/Female	Common bile duct dilation, Chronic pancreatitis	ERCP, replace stent	6 days	Splenic subcapsular hematoma	Conservative
Paredes et al[28]	2013	39/Female	Cholecystectomy, adherent omentum	ERCP, sphincterotomy, stenting	1 hour	Splenic laceration	Splenectomy
Weaver et al[29]	2014	66/Male	Choledocholithiasis	ERCP	Overnight	Splenic subcapsular hematoma	Splenectomy
Ahmad et al[30]	2016	76/Male	Choledocholithiasis	ERCP, sphincterotomy	30 minutes	Splenic capsular avulsion	Splenectomy

ERCP: Endoscopic retrograde cholangiopancreatography.

CASE PRESENTATION

Chief complaints

A 69-year-old male patient presented to our clinic with complaints of jaundice, accompanied by nausea, lower abdominal distension, and pain.

History of present illness

The patient’s symptoms started 1 week ago with no apparent trigger.

History of past illness

Three years ago, the patient was diagnosed with multiple tumors of the sigmoid colon and underwent laparoscopic sigmoidectomy. Pathology revealed multiple malignant tumors of the sigmoid colon. The patient subsequently underwent conventional chemotherapy.

One year ago, the patient exhibited occupying lesions in the intrahepatic bile ducts of the left outer lobe of the liver near the hepatic hilum. The patient subsequently underwent a left lobe hepatectomy and cholecystectomy.

Personal and family history

The patient reported no family history of malignant tumors and no history of smoking or drinking.

Physical examination

The patient's vital signs were as follows: Body temperature, 36.5 °C; heart rate, 80 bpm; respiratory rate, 20 breaths/min; and blood pressure, 103/77 mmHg. Additionally, there was a visible postoperative scar in the anterior midline of the abdomen, as well as abdominal and epigastric tenderness.

Laboratory examinations

Admission liver function tests showed the following: Alanine aminotransferase (ALT) 424.4 U/L, aspartate transaminase (AST) 210.9 U/L, glutamyl transferase (GGT) 1096 U/L, alkaline phosphatase (ALP) 259 U/L, total bilirubin 130.91 μmo1/L, direct bilirubin 71.71 μmol/L, and indirect bilirubin 59.2 μmol/L.

Imaging examinations

Abdominal ultrasound showed dilatation of the bile ducts in the liver. The duodenum was not peristaltic and metastasis was suspected in the duodenum and its periphery in the hepatic portal position.

Admission magnetic resonance cholangiopancreatography (MRCP) (Figure 1A) showed narrowing of the right hepatic duct was at the porta hepatis, which corresponded to a dilation of the intrahepatic bile duct in the right lobe of the liver. No dilatation or narrowing of the common hepatic duct or common bile duct was observed.

Figure 1 Admission magnetic resonance cholangiopancreatography and magnetic resonance imaging. A: Magnetic resonance cholangiopancreatography revealed a narrowing of the right hepatic duct at the porta hepatis; B: The spleen is morphologically normal with a homogeneous parenchymal signal.

Admission magnetic resonance imaging (MRI) of the upper abdomen (Figure 1B) revealed that the spleen was morphologically normal with a homogeneous parenchymal signal. Postoperative changes were observed in the liver and gallbladder. Additionally, there was limited stenosis of the right hepatic duct in the hilar region.

FINAL DIAGNOSIS

The patient was diagnosed with obstructive jaundice, liver tumor (metastasis of colon cancer), and liver insufficiency.

TREATMENT

In conjunction with the expert opinions of other hospitals, to ensure smooth bile drainage and prevent liver failure, the patient underwent ERCP and stent implantation 1 week after admission in our hospital. During the ERCP procedure, the lateral scope was passed smoothly under intravenous anesthesia in the prone position. The esophageal cardia entered the gastric cavity and it was difficult to pass the scope through the pylorus; thus, the anterior scope was replaced by a guide wire which was placed through the pylorus into the jejunum, and then the lateral scope was replaced by inserting a balloon through the guide wire, and repeated attempts were made to enter the descending portion of the duodenum. The balloon guidewire was removed and the main papilla was found on the medial side of the descending portion, which showed a papillary shape with a granular opening. The bile duct was difficult to intubate, the pancreatic duct was accessed, a pancreatic duct guide wire was left in place and the bile duct was visualized by re-accessing the bile duct and administration of contrast into the bile duct. The contrast agent used was iodixanol. The X-ray showed: Bile duct stenosis in the porta hepatis, dilatation of the left hepatic duct, and the right hepatic duct was not visualized. As the bile duct was difficult to intubate, the guidewire was repeatedly entered into the pancreatic duct several times, and in order to prevent ERCP pancreatitis, the papilla was incised to 0.4 cm with an incision knife and a pancreatic stent of 5F diameter and 5 cm length was placed through the pancreatic duct guidewire and pancreatic fluid was seen to drain. After placing an 8.5F diameter, 11cm long unilateral plastic wing stent through the bile duct guidewire, bile was seen to flow out and the operation was completed. Liver function test 24 hours after ERCP revealed ALT 175 U/L, AST 87 U/L, GGT 565 U/L, ALP 142 U/L, total bilirubin 83.9 μmo1/L, direct bilirubin 60.4 μmol/L, and indirect bilirubin 15.8 μmol/L. These indices had significantly improved compared to the previous values.

OUTCOME AND FOLLOW-UP

On the 7^th day after ERCP, the patient had worsening abdominal pain, fever (38.7 °C), poor mental status, nausea, and vomiting, and a hematoma was seen under the palpated splenic hilum on computed tomography (CT) (Figure 2) and MRCP (Figure 3) of the upper abdomen, but the etiology of the disease was not yet clarified. In addition, biliary stent displacement and poor bile drainage were observed. Liver function tests showed an upward trend, and 7 days after ERCP liver function showed the following: ALT 134 U/L, AST 107 U/L, GGT 658 U/L, ALP 212 U/L, total bilirubin 126.8 μmo1/L, direct bilirubin 100.2 μmol/L and indirect bilirubin 26.6 μmol/L. Percutaneous hepatic puncture biliary drainage (PTCD) was performed, resulting in good drainage and the patient's jaundice gradually subsided. Abdominal pain and other symptoms significantly improved two days later.

Figure 2  Computed tomography scan revealed a hematoma in the spleen after endoscopic retrograde cholangiopancreatography.

Figure 3 Magnetic resonance cholangiopancreatography and magnetic resonance imaging after endoscopic retrograde cholangiopancreatography. A: Biliary and pancreatic stents can be visualized and stent migration was considered based on the patient's elevated liver function; B: Magnetic resonance imaging revealed a hematoma in the spleen.

Twelve days after PTCD, the patient had no obvious discomfort. We planned to perform ERCP again to reposition the stent, remove the PTCD drain, and achieve intrahepatic biliary drainage. During the operation, a large mass was observed on the posterior wall of the gastric sinus and the greater curvature of the external pressure side. This caused a narrowing of the gastric sinus lumen and severe deformation of the pylorus, making it impossible to pass an endoscope. To address this, the operation mode was changed and endoscopic pyloric stent placement was performed (Figure 4). The stent was successfully positioned.

Figure 4  Endoscopic pyloric stent placement with minor intraoperative bleeding.

The patient's abdominal CT was reviewed 3 days before discharge (Figure 5), and the splenic hematoma had resolved. Subsequently, the patient attended our hospital every 3 months to have the PTCD drain changed and received radiotherapy at the same time, The patient's abdominal CT was reviewed several times during the year, and the splenic morphology was normal.

Figure 5  A computed tomography scan conducted before discharge showed that the splenic hematoma had disappeared.

DISCUSSION

ERCP is a vital tool for diagnosing and treating pancreatic and bile duct diseases. In this case, a tumor in the hepatic hilum was compressing the bile duct, causing obstructive jaundice. Stent placement via ERCP provided a palliative intervention. Postoperative complications, such as pancreatitis, perforation, and hemorrhage, are common[31,32]. Rare complications have also been reported internationally, such as death caused by air embolism[33], duodenal perforation due to biliary stent displacement[34], and hepatic hematoma[35]. It is important to note that these complications are infrequent. Splenic injuries include splenic subcapsular hematoma, splenic hematoma, splenic capsular avulsion, peri-splenic hematoma, intrasplenic hematoma, splenic laceration, splenic rupture, splenic abscess, and short gastric vessel avulsion.

The risk factors for splenic injury after previous ERCP include calcification and fibrosis of the supporting ligaments, such as the splenocolic and gastrosplenic ligaments, which can cause decreased mobility of the viscera. These risk factors are particularly relevant for patients with cirrhosis and chronic pancreatitis. Excessive traction on the ligaments can result in splenic injury[4]. Abdominal adhesions can also develop after abdominal surgery[5,6]. If a patient experiences abdominal pain, decreased blood pressure or hematocrit, and hemodynamic instability after ERCP, it is important to consider the possibility of splenic injury[7,8]. Depending on the severity of the injury, conservative management[9,10,11], splenectomy[8,12,13], or splenic artery embolization[6,7,14] may be employed to control bleeding after a splenic injury.

Our patient had stenosis of the pylorus and bile ducts due to compression by a hepatic tumor. The endoscope caused excessive traction or shear force when passing through the pylorus and bile ducts, which caused the greater curvature of the stomach to twist and led to splenic injury following excessive traction of the splenic colonic ligament. The patient underwent two major abdominal surgeries, including a left lobe hepatectomy and cholecystectomy. These procedures may have resulted in calcification of the peri-splenic ligament and vascular adhesions, which ultimately contributed to the splenic injury. The clinical symptoms of both biliary stent displacement and splenic haematoma can manifest as abdominal pain and fever, so the symptoms of patient on day 7 after ERCP may have been caused by both of these conditions. Stent displacement can be caused by excessive external compression or oblique vectorial compression resulting from a change in position. This reporte indicates that there is no correlation between stent displacement and splenic hematoma, suggesting that the latter does not cause stent displacement.

CONCLUSION

Splenic injury is a rare complication of ERCP that requires attention. The onset of symptoms can occur rapidly, within minutes, or may be delayed for up to a week. The severity and type of injury may also vary. Therefore, it is essential to be vigilant, conduct a careful investigation, and appropriately treat or manage patients who present with symptoms after ERCP to treat such complications.

ACKNOWLEDGEMENTS

When preparing this paper, invaluable guidance and assistance was received from my supervisor, Ms. Yu-Xia Wei. I would like to express my sincerest gratitude to her for her invaluable support.