Abstract
We report a case of a 60-year-old male who developed a large retroperitoneal haematoma following endoscopic retrograde cholangiopancreatography (ERCP). Initial imaging suggested a distal common bile duct calculus and a small highly vascularized lesion in the periampullary region, but ERCP revealed no stones, and no sphincterotomy or balloon dilation was performed. Post-procedure, the patient developed severe abdominal pain with subsequent haemodynamic instability. Computed tomography angiography demonstrated active bleeding from aneurysm of the inferior pancreaticoduodenal artery, successfully embolized via the superior mesenteric artery. The patient recovered with supportive care and percutaneous drainage of residual haematomas. This case highlights the rare but serious complication of vascular injury following ERCP, even without invasive biliary interventions.
Introduction
Endoscopic retrograde cholangiopancreatography (ERCP) is a common procedure for diagnosis and treatment of biliary and pancreatic diseases. Although generally safe, complications include pancreatitis, gastrointestinal bleeding, infection, and rarely vascular injuries. Bleeding may occur immediately following ERCP, be self-limited, or present in a delayed fashion, becoming clinically evident from several hours up to 7–10 days after the procedure. Retroperitoneal bleeding secondary to aneurysm rupture is uncommon but potentially life-threatening. Prompt recognition and intervention are critical for patient survival.
We present the case of a 60-year-old man who developed haemorrhage from the inferior pancreaticoduodenal artery following ERCP, most likely secondary to rupture of an aneurysm or pseudoaneurysm.
Case report
A 60-year-old male with former laparoscopic cholecystectomy presented with a 2-month history of intermittent right upper quadrant abdominal pain, gradually becoming constant. He had no previous history of pancreatitis. Blood tests indicated mild renal impairment; all other parameters were within normal limits. An abdominal computed tomography (CT) revealed a 7 mm biliary duct with signs of sludge (Fig. 1). The pancreatic duct was 4 mm. A small, highly vascularize lesion was seen in the duodenal wall close to the papilla Vateri. The presence of biliary duct sludge and a suspected periampullary malignant lesion prompted ERCP.
Pre-procedural CT.
During the procedure, the duodenal wall and ampulla of Vater appeared normal. Cannulation of the common bile duct was successful on the first attempt, with no evidence of stones or other pathology on contrast injection. No sphincterotomy or balloon dilation was performed. The guidewire and cannulation catheter dislodged, and a subsequent attempt with guidewire cannulated the pancreatic duct; the procedure was terminated without further intervention or contrast administration.
Three hours later the patient developed severe diffuse abdominal pain. Vital signs were stable and analgesia and intravenous fluids were initiated for suspected post-ERCP pancreatitis, although serum amylase was only 152 U/L. Eight hours post-procedure, haemoglobin was 17 g/dl, white blood cell count 16.9 × 109/L, amylase 195 U/L, and lipase 622 U/L. Vital signs remained stable and the patient was observed overnight in the intensive care unit. There were no symptoms or clinical signs of gastrointestinal bleeding.
The following day a porto-venous CT scan (without angiography) revealed a large retroperitoneal haematoma in the right upper quadrant without signs of ongoing contrast extravasation. Day 5 after ERCP, the patient developed hypotension (BP 79/55 mmHg) and tachycardia (HR 137 bpm). Arterial blood gas: pH 7.41, pCO₂ 4.4 kPa, Hb 10.5 g/dl, lactate 3.9 mmol/L, HCO₃− 22 mmol/L, BE −3.3 mmol/L, and CT angiography demonstrated active bleeding from the inferior pancreaticoduodenal artery.
The patient received packed red blood cells transfusion and was transferred to a tertiary centre for intervention radiology. The angiogram identified a bleeding from an aneurysm of the inferior pancreaticoduodenal artery (Fig. 2). Haemostasis was achieved by endovascular coil embolization performed via the superior mesenteric artery into the inferior pancreaticoduodenal artery, with deployment of coils both proximal and distal to the site of bleeding, including two Medtronic Concerto™ detachable coils (7 mm × 30 cm and 5 mm × 15 cm) and eight Boston Scientific VortX Diamond-18 coils (3 × 3.3 mm and 4 × 3.7 mm) (Fig. 3). Adjunctive embolization was also performed using absorbable gelatin sponge material, including Spongostan and EmboCube 2.5 mm particles (Merit Medical).
Angiography showing inferior pancreaticoduodenal artery pseudaneurysm (arrow).
Coilembolization of inferior pancreaticoduodenal artery pseudaneurysm (arrow).
The patient stabilized haemodynamically and returned to the local hospital. Follow-up CT 4 days later revealed multiple organized intra-abdominal fluid collections consistent with haematoma. A percutaneous drain was placed, yielding sterile fluid, and removed after 4 days. The patient was discharged home 15 days post-ERCP.
Discussion
Bleeding following ERCP in the absence of sphincterotomy is exceedingly uncommon, with a reported incidence <1% [1, 2]. Although vascular injury by a soft guidewire remains theoretically possible, this mechanism appears unlikely in the present case. Biliary cannulation was uncomplicated and performed without therapeutic intervention or sphincterotomy, making direct injury to the inferior pancreaticoduodenal artery improbable Furthermore, there was no evidence of intraluminal gastrointestinal bleeding during or immediately after the procedure.
Acute pancreatitis is a recognized cause of vascular complications, including thrombosis and pseudoaneurysm formation, reported in ~1.3%–10% of cases [2]. However, these complications typically occur late in the course of severe pancreatitis and rarely in the course of mild pancreatic irritation of the type encountered in this patient after the secondary guidewire cannulation of the pancreatic duct [3].
The prevalence of visceral artery aneurysms is low (0.1% to 2%), most commonly occurring in the splenic artery [4, 5]. Pseudoaneurysms of the gastroduodenal artery or the related pancreaticoduodenal arcade vessels are extremely rare, comprising ~5% of all visceral artery pseudoaneurysms. Pancreaticoduodenal artery aneurysms are most commonly associated with pancreatitis or previous surgical and interventional procedures [6]. Patients most frequently present with abdominal pain, while a palpable abdominal mass may occasionally be detected on physical examination [4]. Size is not a reliable predictor of rupture for pseudoaneurysms [2, 6].
When pseudoaneurysms involve the distal branches of the pancreaticoduodenal artery arcade, the reported rupture rate is 50%–90%. However, free rupture of these distal branches usually occurs retroperitoneally, is often contained, and is less frequently fatal. The inferior pancreaticoduodenal artery arises as a distal branch of the superior mesenteric artery and supplies both the duodenum and the pancreatic head. Consequently, haemorrhage from this vessel may extend into both the intraperitoneal space and the retroperitoneal space).
Endovascular intervention has emerged as a highly effective treatment modality for visceral artery aneurysms, with reported technical success rates ranging from 98% to 100% [7]. Potential complications of embolization include end-organ infarction, post-embolization syndrome, re-bleeding, and reperfusion of the pseudoaneurysm.
This case highlights the need for clinicians to consider vascular injury, even in the absence of invasive biliary interventions such as sphincterotomy or balloon dilation, as a rare but serious post-ERCP complication. When CT identify contrast enhanced areas without a definite lesion, supplementary CT recordings after contrast infusion might be considered upfront to endoscopic diagnostics and interventions like duodenoscopy, endoscopic ultrasound (EUS) or ERCP.
Conflicts of interest
None declared.
Funding
None declared.
