A 72-year-old woman, with diabetes mellitus and hypertension as the only personal history of interest, came to the Emergency Department with a clinical picture of mucocutaneous jaundice and choluria associated with epigastric pain.
Physical examination revealed right hypochondrium pain without signs of peritonitis.
Blood tests showed bilirubin 5.6 mg/dl, AST 608 IU/l and ALT 720 IU/l.
Abdominal ultrasound showed dilated common bile duct stones (22.4 mm) and gallstones.
ERCP confirmed cholelithiasis. Endoscopic sphincterotomy was performed and choledocholithiasis was extracted.
Two hours after the test, the patient begins with sudden pain in the right hypochondrium.
Physical examination revealed right hypochondrium pain with signs of peritoneal irritation, tachycardia, tachypnea and hypotension of 95/60.
Analytically, bilirubin 3.4 mg/dl, AST 315, amylase 64 U/l, ALT 450, leukocytes 15400/mm3, hemoglobin 5.5 g/dl and creatinine 2.4 mg/dl were highlighted.
Abdominal CT scan revealed an intraperitoneal free fluid in both drops and Douglas bag bottom, as well as a hypodense lesion with poorly defined borders in the right hepatic lobe and an aerobilia in the bile duct.
These findings and the persistence of hemodynamic instability was decided to surgically intervene the patient.
At surgery, hemoperitoneum and a subhepatic hematoma of 8 cm partially ruptured in hepatic segments V-VI are observed.
The patient was evacuated and hemostasis was achieved with electrocoagulation and Surgicel®, leaving a Jackson-Pratt drain in the right subphrenic space.
The patient was admitted to the ICU for 48 hours.
The patient did not present new episodes of bleeding and a control CT did not show any collection, and was discharged 4 weeks after the intervention.
