A Case of Intra-abdominal Hemorrhage from Liver Caused by Therapeutic Endoscopic Retrograde Cholangiopancreatography

Abstract

We experienced a case of intra-abdominal hemorrhage stemming from liver injury caused by the detachment of a hepatic-intestinal adhesion in a woman in her fifties who had undergone gastrointestinal reconstruction for pancreatic cancer. Three years after the operation, she was diagnosed as having an intrahepatic bile duct stone and underwent therapeutic endoscopic retrograde cholangiopancreatography (ERCP) with a double-balloon endoscope. After completion of the operation, she experienced sudden cardiac arrest. Contrast-enhanced computed tomography (CT) was performed after resuscitation which revealed intra-abdominal hemorrhage and extravascular leakage on the surface of the left lobe of the liver. Argent angiography was immediately performed revealing hemorrhage from branch A3 of the left hepatic artery. Based on CT and angiographic findings, the hemorrhage was revealed to have been the result of liver injury. Reexamination of preoperative images showed that the afferent loop was attached over its length to the liver surface from which the hemorrhaging occurred, indicating a hepatic-intestinal adhesion. It was thus likely that the endoscopic procedure caused detachment of the adhesion and damage to the liver capsule, resulting in hemorrhaging. It is important to note that while therapeutic ERCP is a very useful therapeutic modality, it is associated with complications, including rare, procedure-specific, adhesion-related complications, especially in patients who have previously undergone gastrointestinal reconstruction.