Splenic injury complicating ERCP
We report a case of a 64-year-old man who sustained a splenic injury following ERCP. He was admitted to hospital with obstructive jaundice, and he reported a past medical history of coronary heart disease, right lower pulmonary lobectomy due to lung cancer 5 years previously and nephrotic syndrome. The basic laboratory tests were normal except for liver function tests, which showed a bilirubin level of 12.6 mg/dL (reference level, 0.3-1.2 mg/L), an alkaline phosphatase level of 419 U/L (reference level, 40-129 U/L), and an amylase level of 708 U/L (reference level, 28-128 U/L). His clotting profile was normal.\nThe abdominal computed tomography (CT) showed a mass at the head of the pancreas with dilated pancreatic and common bile duct and additionally some paraortic and mesenteric lymph nodes. The CT was performed without intravenous contrast medium due to renal insufficiency. An upper GI endoscopy revealed duodenal stenosis (treated with balloon dilatation) and a deformed ampulla of Vater secondary to the tumor. An ERCP followed which confirmed the above findings and a plastic stent was placed in the common bile duct and draining was achieved.\nSix hours after the procedure the patient complained of epigastric pain. He was afebrile with a pulse rate of 85 beats/ min and a systolic and diastolic blood pressure of 100 and 70 mm Hg respectively. The physical examination revealed a soft abdomen with mild tenderness over the epigastrium and left upper quadrant without peritoneal signs. The next day (18 h after the procedure) a second CT was performed which showed a homogeneous mass lesion of the left subdiaphragmatic region in keeping with a splenic hematoma (). A hemoperitneum and a plastic biliary stent were also present. Laboratory blood tests including complete blood count showed a decrease of the hemoglobin (from 14.1 to 8.0 g/dL) and mild leukocytosis: 11.3 k/mL. Subsequently, an emergency surgical solution was offered to the patient. After entering the peritoneal cavity the following findings were observed: a) rupture at the hilum of the spleen; and b) a solid mass in the head of the pancreas obstructing the duodenum. Splenectomy was performed () with meticulous hemostasis and enterogastrostomy (stomach - jejunum) in order to bypass the obstructed duodenum.