endoscopic retrograde cholangiopancreatography ( ercp ) is a well - established modality in the management of pancreaticobiliary conditions .
the procedure carries with it several well - recognised complications , as well as other much less common ones such as splenic injury , which can be associated with significant morbidity or mortality . since the first reported case of post - ercp splenic injury in 1989 , there have been a total of only 19 cases reported to date in the english , german and spanish literature [ 1 , 2 , 3 , 4 , 5 , 6 , 7 , 8 , 9 , 10 , 11 , 12 , 13 , 14 , 15 , 16 , 17 , 18 , 19 ] .
herein , we report on a patient who had a peri - splenic haematoma following ercp and was successfully managed conservatively .
we also review in detail all of the published cases to better understand this rare complication .
a 59-year - old woman presented to the hospital with progressive right upper quadrant abdominal pain for 7 days accompanied by profound jaundice . prior to this admission , she had presented to another hospital 7 months previously with similar symptoms and was diagnosed with choledocholithiasis .
she underwent an ercp with sphincterotomy and stenting of the common bile duct but did not return for a planned cholecystectomy and removal of stent .
her past medical history included untreated hepatitis c without cirrhosis , intravenous drug use , alcohol abuse and a previous laparotomy for ovarian cystectomy .
her regular medications included methadone 80 mg daily and escitalopram 40 mg daily . at presentation ,
her blood pressure was 104/70 mm hg and all other vital signs were within normal limits .
her liver function tests were elevated : bilirubin 120 mol / l ( normal , < 20 mol / l ) , alkaline phosphatase 1,490 u / l ( normal , 30110 u / l ) , gamma - glutamyl transferase 850 u / l ( normal , < 38 u / l ) , alanine transaminase 196 u / l ( normal , < 34 u / l ) and aspartate aminotransferase 145 u / l ( normal ,
a liver ultrasound demonstrated cholelithiasis with evidence of intrahepatic and proximal extrahepatic bile duct dilatation .
she also underwent liver magnetic resonance imaging with a magnetic resonance cholangiopancreatography , which revealed a large impacted stone in the neck of the gallbladder causing obstruction of the common hepatic duct , just proximal to the previously inserted stent , associated with extensive pre - stenotic , intra- and extrahepatic ductal dilatation which was in keeping with mirizzi syndrome .
the stent was removed with a basket and the common bile duct was cannulated easily through the pre - existing sphincterotomy .
the cholangiogram confirmed tight stenosis in the upper third of the main bile duct in keeping with magnetic resonance cholangiopancreatography findings .
the procedure was technically difficult requiring a sustained long scope position to achieve biliary cannulation and stent placement .
approximately 4 h after the procedure , routine nursing observations identified newly developed hypotension with a blood pressure of 83/50 mm hg and a heart rate of 70 beats / min .
the patient was otherwise asymptomatic , afebrile and did not complain of any abdominal pain .
physical examination did not reveal any abdominal tenderness or signs of peritonitis and there was no evidence of gastrointestinal bleeding or overt dehydration .
following the administration of 500 ml of intravenous colloid ( 4% albumin ) , her systolic blood pressure stabilised at 103 mm hg which was similar to that on admission . on the next morning , routine blood tests showed a haemoglobin level of 57
g / l ) . platelet count and coagulation studies were unchanged and within normal limits .
she remained haemodynamically stable and physical examination was again unremarkable , and without evidence of gastrointestinal or any other obvious source of bleeding .
given that the ercp and stent exchange were uneventful and performed through a pre - existing sphincterotomy , a gastrointestinal bleeding source was felt to be unlikely and an urgent abdominal and pelvic computed tomography ( ct ) scan was organised .
the ct showed a peri - splenic haematoma and moderate volume of hyperdense abdominal free fluid , consistent with a haemoperitoneum ( fig .
1 ) . considering she was haemodynamically stable , a decision was made for conservative management including a blood transfusion of 3 units of packed cells . in the next 48 h ,
the patient made an uneventful recovery and was subsequently discharged from hospital with a plan for an eventual elective cholecystectomy .
she was followed up as an outpatient 3 weeks later ; she was clinically well with normal - range haemoglobin and bilirubin .
since 1968 , when ercp was first introduced by mccune et al . , there has been significant advancement and increased utility of this procedure for diagnostic and now mainly therapeutic purposes in managing pancreaticobiliary conditions .
common complications of this procedure as reported by the american society for gastrointestinal endoscopy ( asge ) in 2012 include pancreatitis ( approx .
3.5% ) , haemorrhage ( especially following sphincterotomy ; 1.3% ) , cholangitis ( 1% or less ) , cardiopulmonary complications ( 1% ) , perforation ( 0.10.6% ) and overall mortality ( 0.33% ) .
splenic - related injuries have always been considered a rare but recognised complication of endoscopy , owing to the close anatomical proximity of the spleen to the stomach and colon .
other reported rare complications of ercp include liver laceration and disruption of the transverse mesocolon with resultant colonic ischaemia [ 1 , 2 ] . prior to 1975
, 2 large case series comprising over 12,000 patients who underwent colonoscopy and endoscopy did not find a single case of splenic injury . as of 2014 ,
weaver et al .   reported that there were over 60 cases of splenic injury following colonoscopy but only 13 reports of a similar injury after ercp in the literature .
the first case of splenic injury following ercp was reported by trondsen et al .   in 1989 .
a female patient admitted with acute gallstone pancreatitis was found to have suffered a complete avulsion of the splenic capsule necessitating splenectomy approximately 15 h after ercp .
since then , similar cases have been reported over the following 27 years albeit of differing patient and procedural characteristics .
the types of splenic injuries that occur are limited , and the proposed mechanism of injury and predisposing factors have had little differing opinion among the authors , as will be discussed below . at the time of this report , a total of 19 cases of ercp - related splenic injury were found in the english , german , and spanish literature ( summarised in table 1 ) .
these published cases included 11 female and 8 male patients with a median age of 57 years ( range , 3382 years ) .
the exact mechanism(s ) of injury to the spleen during ercp remains unresolved ; however , excessive scope - related direct , traction or shear forces appear most likely causative . as the side - viewing duodenoscope
is usually advanced into a loop ( long ) position in order to reach the second part of the duodenum , the scope has to be torqued to the right and withdrawn partially ( short position ) to bring the ampulla into a satisfactory position for cannulation .
this manoeuvre causes initial  bowing  of the endoscope within the stomach , likely translating into direct forces towards surrounding organs including the spleen , followed by torsion on the greater curvature of the stomach .
adjacent viscera that are anatomically attached , such as the spleen , could then be injured by traction forces , manifesting in the form of splenic capsular tears or vascular avulsion [ 6 , 7 , 8 , 9 , 10 , 11 , 12 ] . a sustained long scope position , as in our case ,
there are at least 3 predisposing factors that have been postulated to lead to splenic injury during ercp ( table 2 )
. decreased movement between the spleen and adjacent structures , excess traction on the gastrosplenic ligament and direct scope - induced trauma have been hypothesised [ 3 , 13 ] .
five cases involved patients with either known or newly diagnosed ( intraoperative ) chronic pancreatitis , and it has been suggested that calcification and fibrosis of the attaching ligaments preclude any compensatory mobility between the surrounding organs [ 2 , 3 , 4 , 15 , 16 ] .
adhesions from prior abdominal surgery , as in our case , were also found to be associated with splenic injuries for the same reason [ 2 , 12 , 13 , 17 ] .
in fact , given the intimate proximity between the spleen and tail of pancreas , acute and post - ercp pancreatitis is increasingly recognised as a risk factor for splenic parenchymal injuries . technically difficult cases due to altered
anatomy or other patient factors may result in prolonged procedure time and more scope manipulation , thereby increasing the risk of excessive ligamentous tension and injury .
stomach inflation itself , in the opinion of the authors of at least 2 cases , may well render the highest ( and shortest ) short gastric vessels vulnerable to avulsion injury [ 2 , 14 ] .
alternatively , direct splenic trauma by the duodenoscope is a possibility , which often results in injury to the medial or hilar surface of the spleen .
it is worth noting that splenic injuries have occurred even in non - technically difficult procedures , as highlighted by wu and katon   and chavalitdhamrong et al . .
of the 19 cases of post - ercp splenic injuries , 10 procedures were performed without difficulty , 7 were difficult , and in 2 it was unreported .
in addition , although therapeutic ercp historically carries a higher morbidity and mortality than diagnostic ercp [ 1 , 21 ] , the difference was not significantly demonstrated in our review .
signs and symptoms that should alert a clinician to a possible splenic injury are not specific and overlap considerably with significantly more common complications of ercp , such as pancreatitis , perforation and post - sphincterotomy bleeding .
the typical presentation may include abdominal pain with or without signs of peritonitis ( often left upper quadrant and epigastric ) , hypotension and/or tachycardia [ 1 , 2 , 3 , 4 , 5 , 6 , 7 , 8 , 9 , 10 , 11 , 12 , 13 , 14 , 15 , 16 , 17 , 18 , 19 ] .
fever was found in only 1 case who represented 10 days later  in the setting of a previously known splenic haematoma that became secondarily infected from a skin source and turned into an abscess .
it must also be emphasised that there is a considerably variable time interval between developing symptoms and index ercp . while someone who complains of acute abdominal pain minutes after the procedure would immediately raise suspicion of a related complication , delayed presentations of up to 6 days have been reported and may be overlooked as an unrelated issue .
although in 5 out of 19 cases , the patient was taken directly to theatre for emergency laparotomy based on strong clinical suspicion alone , an abdominal ct scan is still considered the test of choice to investigate any suspected severe complication [ 23 , 24 ] . alternatively , abdominal ultrasound has also been used in 2 cases which revealed findings that supported the indication for surgery [ 5 , 13 ] .
common pathologic findings on ct include moderate to large volume of free fluid ( haemoperitoneum ) , subcapsular or peri - splenic haematoma , and splenic laceration
. often the exact diagnosis can only be ascertained intraoperatively , as in cases due to avulsion of blood vessels and splenic capsular tears .
management of the patient who has likely suffered a post - ercp splenic injury does not always entail a laparotomy . in this review ,
indeed , management should be tailored to the patient 's clinical state and with regard to their haemodynamic stability .
trauma guidelines should also be followed as per any blunt splenic trauma , as the management is similar despite differing mechanisms of injury .
early involvement of the surgical team is prudent for any ercp - related complication , particularly for splenic injury .
a surgical approach is usually indicated in patients who experience haemodynamic compromise despite adequate resuscitation , while those who are clinically stable may well be observed and treated conservatively by an experienced clinician . in select cases ,
a splenorrhaphy rather than a splenectomy may be considered at laparotomy for stable patients with an identifiable splenic injury that is repairable [ 3 , 10 ] .
more recently , splenic artery embolisation has emerged as a useful adjunct to non - operative management and is increasingly used in trauma settings .
the patient in our case underwent a technically difficult but successful ercp with stenting for biliary obstruction , and subsequently experienced an episode of hypotension with no abdominal pain and a drop in haemoglobin the next day without any other concerning features .
ercp - related gastrointestinal bleeding appeared unlikely given that biliary cannulation and stenting was performed through a pre - existing sphincterotomy .
the ct showed a peri - splenic haematoma with haemoperitoneum , which we suspect was due to splenic capsular injury , likely associated with forces from a sustained long scope position required to successfully perform ercp and stent placement .
, splenic injury with splenic haematoma or haemorrhage should be recognised as a rare but clinically significant complication of ercp .
clinical suspicion should be raised if the procedure has been difficult , requiring a sustained long position of the duodenoscope .
symptoms may include initial asymptomatic post - procedural hypotension , left upper quadrant pain , and/or markedly reduced haemoglobin with no haematemesis or melaena .
consideration should also be given for including the rare risk of splenic injury in the consent information for ercp .
 splenic injury following endoscopy is a rare but potentially fatal complication . 
 while this has been found to occur more frequently after colonoscopy , splenic injury following endoscopic retrograde cholangiopancreatography ( ercp ) remains highly uncommon since its first reported case in 1989 . 
 indeed , there have been only 19 such cases reported in the english , german , and spanish literature collectively over the past 27 years . 
 we report on a 59-year - old woman who developed a peri - splenic haematoma diagnosed on abdominal computed tomography the day following ercp and stenting for mirizzi syndrome . 
 the patient was treated conservatively and made a full recovery . 
 we reviewed all cases of post - ercp splenic injuries reported to date and discuss the published opinions on the likely mechanism of injury , predisposing factors , presenting features , investigation , and treatment options . 
 ultimately , patient outcome relies on clinical suspicion of this rare complication following ercp . 
Introduction
Case Report
Discussion
Statement of Ethics
Disclosure Statement