Management of Liver Hematoma with Hemoperitoneum after ERCP and Liver Biopsy
Liver hematoma with hemoperitoneum following ERCP and liver biopsy should be managed initially with non-operative treatment including close hemodynamic monitoring, volume resuscitation, and angiography with embolization if the patient is hemodynamically stable, reserving surgical intervention for those with hemodynamic instability or peritonitis.
Initial Assessment and Stabilization
Immediate Evaluation
- Assess hemodynamic status (blood pressure, heart rate, urine output)
- Obtain complete blood count, coagulation profile, and liver function tests
- Perform urgent contrast-enhanced CT scan to evaluate extent of hematoma and active bleeding
Hemodynamic Stabilization
- Establish large-bore IV access
- Administer crystalloid fluids and blood products as needed
- Correct any coagulopathy (target platelet count >50,000-60,000/mm³ and INR <1.5) 1
Management Algorithm
For Hemodynamically Stable Patients
Non-operative management (NOM) is the first-line approach 1
- Intensive care unit admission
- Continuous hemodynamic monitoring
- Serial hemoglobin measurements
- Repeat imaging as needed to assess hematoma progression
Angiography with embolization (AG/AE) if:
- Evidence of ongoing bleeding
- Expanding hematoma
- Decreasing hemoglobin despite resuscitation
- Hepatic artery pseudoaneurysm identified 1
For Hemodynamically Unstable Patients
Immediate surgical intervention is indicated for:
- Persistent hemodynamic instability despite resuscitation
- Signs of peritonitis
- Abdominal compartment syndrome 1
Surgical options include:
- Direct hemostasis of bleeding site
- Packing
- Selective hepatic artery ligation
- Partial hepatectomy in severe cases 2
Management of Specific Complications
Biliary Complications
- For symptomatic or infected bilomas: percutaneous drainage 1
- For biliary leaks: combination of percutaneous drainage and endoscopic stenting 1
- For biliary fistula: laparoscopic lavage/drainage and endoscopic stenting 1
Abdominal Compartment Syndrome
- Monitor intra-abdominal pressure
- Perform decompressive laparotomy if abdominal compartment syndrome develops 3
Delayed Hemorrhage
- Be vigilant for delayed hemorrhage which can occur up to 15 days after the procedure 4
- Maintain close follow-up even after discharge
- Instruct patients to return immediately if they develop increasing abdominal pain, dizziness, or other signs of bleeding
Post-Procedure Monitoring
In-Hospital Monitoring
- Minimum observation period of 24-48 hours
- Serial clinical examinations
- Regular vital sign checks and hemoglobin monitoring
- Follow-up imaging before discharge if clinically indicated
Discharge Criteria
- Hemodynamically stable without support
- Stable or improving hematoma on imaging
- No evidence of ongoing bleeding
- Adequate pain control with oral medications
- Clear understanding of warning signs requiring return
Important Considerations
Risk Factors for Bleeding Complications
- Advanced age (>50 years)
- Coagulopathy (INR >1.5, platelets <50,000/mm³)
- Multiple biopsy passes
- Renal failure
- Sepsis 1
Technical Factors to Reduce Future Risk
- Use of ultrasound guidance for procedures
- Limiting the number of passes during biopsy
- Selection of appropriate needle size
- Ensuring operator experience (>100 procedures) 1
Pitfalls and Caveats
- Do not underestimate the risk of delayed hemorrhage, which can occur up to 15 days after the procedure 4
- Avoid premature discharge of patients with significant hematomas
- Do not restart anticoagulants too early (generally wait 48-72 hours for antiplatelet therapy and at least 24 hours for warfarin) 1
- Remember that hemodynamic stability can be deceptive in young patients who can compensate well until sudden decompensation
- Consider the possibility of hepatic artery pseudoaneurysm, which requires prompt embolization to prevent rupture 1
By following this management approach, most patients with liver hematoma and hemoperitoneum following ERCP and liver biopsy can be successfully managed non-operatively, with surgical intervention reserved for those with hemodynamic instability or other specific indications.