A 79-year old woman who had undergone endoscopic placement of a temporary biliary plastic stent because of irretrievable biliary stones was admitted to the hospital for repeat endoscopic retrograde cholangiopancreatography (ERCP). She was free of symptoms at admission. Liver enzymes and serum bilirubin levels were normal. On ERCP, the proximally migrated biliary stent was extracted with biliary balloon inflation. Because all of the remaining stones could not be extracted, a new 8.5 F biliary plastic stent was inserted into the choleduct.

After recovery from anesthesia, the patient described right upper-quadrant pain. Vital findings and blood tests including complete blood cell count and amylase and liver tests were normal. There was gas at the right upper site on the abdominal radiograph (Figure 1). Ultrasonography and abdominal computed tomography revealed subcapsular liver hematoma (Figure 2) and pleural effusion.

FIGURE 1. Abdominal radiograph demonstrating gas shadow at the right upper quadrant.

FIGURE 2. Computed tomographic scan showing hematoma formation.

At the follow-up, she had no fever; however, blood tests revealed mild leukocytosis and increasing C-reactive protein level. Because of her pain and dyspnea, a percutaneous drainage catheter was inserted on the third day of hospitalization. Abdominal radiograph showed normal findings and her pain decreased gradually. The catheter was removed 3 days later and the patient was discharged. She had no problem at the 1-month follow-up period.

ERCP-associated complications may vary according to age groups. Young age is a risk factor for post-ERCP pancreatitis. On the contrary, bleeding is seen more commonly in the elderly persons (Koklu, Parlak, Yuksel, & Sahin, 2005). Most of the bleeding cases are sphincterotomy-associated; bleeding presenting as subcapsular liver hematoma is a rare complication of ERCP (de la Maza Ortiz et al., 2019; Imperatore et al., 2018; Kocak, Ergul, Akbal, Koklu, & Karakayali, 2012; Sommariva et al., 2019). It occurs as a consequence of intrahepatic small vessel laceration (Sommariva et al., 2019). Guide wire, biliary stenting, and balloon inflation may cause such injuries (Imperatore et al., 2018; Kocak et al., 2012). Although most of the cases heal with conservative management, some need radiological or surgical intervention. Because of its life-threatening potential, ERCP-associated subcapsular liver hematoma needs careful consideration (de la Maza Ortiz et al., 2019). Abdominal radiography is an easy and simple test at the beginning of the diagnostic pathway.

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