PMC7298556_01
Flowchart: review process.
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After 8 h of ERCP, she experienced sudden abdominal pain and pallor, laboratory tests and abdominal radiography showed significant gastric distension (Fig. 1) and raised the hypothesis of blocked duodenal perforation, without pneumoperitoneum or complicated acute cholecystitis.
Abdominal x-ray showing gastric distension.
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Antibiotic therapy was initiated with ciprofloxacin 400 mg every 12 h and metronidazole 500 mg every 8 h, and a CT scan of the abdomen was performed and showed subcapsular hematoma of about 15 cm in diameter, affecting liver segments VI, VII and VIII, with air and a small amount of perihepatic free fluid (Fig. 2).
Abdominal CT showing HSH of about 15 cm, affecting liver segments 6, 7 and 8 with permeate air and small amount of perihepatic free liquid.
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Intraoperatively, a minimal amount of hemoperitoneum, a gallbladder with thick and delaminated walls, and subcapsular hematoma affecting the right lobe of the liver with oozing bleeding in segment VI were identified (Fig. 3).
Intraoperative photography showing discrete hemoperitoneum, enlarged liver with HSH affecting right lobe with bleeding segment VI.
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Postoperatively, after receiving 03 units of packed red blood cells, she maintained hemodynamic stability and was submitted to arteriography - in an attempt to identify the source of bleeding - with no signs of extravasation (Fig. 4).
Arteriography with no signs of leakage.
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She underwent control a CT scan (Fig. 5) on the 22nd postoperative day, which still showed hepatic hematoma, without free fluid, and with no sings of thrombosis.