Clinical Case Summary

A 23-year-old female presented with epigastric pain, jaundice, and elevated liver enzymes. Imaging confirmed a mildly dilated common bile duct (CBD) with multiple filling defects. ERCP revealed a normal ampulla and a half-sphincterotomy was performed with three stones retrieved via balloon trawl. The procedure was uneventful, and she was discharged the same day.
Three days later, she re-presented with dizziness, melaena, and a haemoglobin drop from 127 g/L to 85 g/L. Gastroscopy demonstrated active oozing from the sphincterotomy site, managed successfully with placement of a fully covered metal stent (FCMS). She remained stable and was discharged with outpatient follow-up.
Three weeks later, she re-presented with partial stent blockage and underwent repeat ERCP for stent removal and duct clearance. Within 24 hours, she developed acute left shoulder tip and chest pain. Cardiac investigations were negative. CT imaging demonstrated a large haemoperitoneum and a bulging splenic haematoma without active bleeding, confirmed on a diagnostic laparoscopy .
She was managed conservatively in intensive care and follow up imaging confirmed complete resolution of the haematoma.
This case illustrates splenic haematoma as a rare yet significant complication of ERCP, with only a handful of cases described in the literature. Proposed mechanisms involve shear forces transmitted via the splenogastric ligament, typically in patients with known risk factors such as intra-abdominal adhesions, previous surgery, chronic pancreatitis, or cirrhosis. However, this case highlights its occurrence in a young, healthy patient with no risk factors, suggesting procedural technique or anatomical variation to be a potential trigger for injury. Symptoms such as shoulder or upper quadrant pain following ERCP should prompt consideration of splenic injury. Early recognition is key, as many cases resolve with conservative management but may carry a risk of life-threatening bleeding if unrecognised.

References

MRCP Image Demonstrating CBD Filling Defects
Coronal MRCP showing a mildly dilated common bile duct with multiple signal voids consistent with choledocholithiasis.
ERCP Image Showing Duct Clearance
Fluoroscopic image during ERCP showing balloon trawl and retrieval of multiple CBD stones following half-sphincterotomy.
Blood Results Demonstrating Haemoglobin Drop
Laboratory panel showing haemoglobin decline from 127 g/L to 85 g/L following gastrointestinal bleeding.
Gastroscopy Image Demonstrating Oozing and FCMS Placement
Endoscopic image showing active oozing at the sphincterotomy site and successful placement of a fully covered metal stent.
CT Image of Splenic Haematoma
Axial CT abdomen showing extensive haemoperitoneum and a bulging splenic haematoma in the left upper quadrant.
Follow-up CT Confirming Resolution
Interval CT imaging showing complete resolution of the previously identified splenic haematoma.