The use of endoscopic techniques is advised, with the potential risks carefully weighed against its benefits. The incidence of complications ranges from 2.5% to 8%, of which 1.67% are severe [3,4]. Mortality is higher in therapeutic ERCP at 0.4-0.5% compared to 0.2% in diagnostic ERCP [5].

Clinically evident bleeding occurs in 0.1% to 2% of cases, typically at the site of sphincterotomy [6]. Subcapsular hematoma is another infrequent hemorrhagic complication, first reported in 2000 by Ortega et al [7]. The exact incidence is difficult to determine because many patients may course asymptomatically, and post ERCP follow-up imaging studies are not routinely, unless indicated for other reasons [8].

The pathophysiology of this condition is not fully understood, but two potential mechanisms have been proposed. The first involves direct injury to small intraparenchymal vessels caused by the guidewire. The second suggests a lesion of the Glissonian pedicle caused by traction of the ballon during stone extraction [2]. The use of a guidewire was mentioned in 80.3% of the reviewed publications. Nonetheless, in the remaining 19.7%, no statement was made in this regard, as in this case, being unable to ascertain the device responsible for the lesion.

García et al. reported a mean age of presentation of 59 years, with a gender distribution of 58% women and 35% men. Choledocholithiasis was the most common indication for ERCP (72.7%), followed by stent replacement (6%) and ampullary tumors (6%), which coincides with characteristics of or case. Only 6.4% of the reports confirmed the use of anticoagulant therapy [9]. 

The latest comprehensive review reveals that the most common symptoms of presentation are abdominal pain (83%), anemia (56.7%), hypotension (28.7%), fever (18.3%) and omalgia (13.3%). The majority of cases are diagnosed within the first 48 h post-procedure (77.8%), with almost half of them (40.7%) presenting immediately (within the first 12 h) [1] as seen in the patient described. However, Roldan et al referred a case identified 15 days after the endoscopic intervention [10].

Cases mentioning a decrease in hemoglobin have exhibited a higher frequency of surgical or percutaneous intervention (63%) [9], but other laboratory tests are unspecific. The percentage of hematoma rupture is 23.7%, resulting in a mortality rate of 21.4% [1]. This underscores the importance of early recognition and continuous monitoring of indicators of hypovolemia and peritoneal irritation.

The most utilized diagnostic method is CT scan (91.4%), with concurrent application of ultrasound at 22.4%. This can be attributed to the necessity for thorough characterization before making therapeutic decisions, although hemodynamic instability may preclude its use. The predominant location is the right lobe (87.3%), as in the case discussed, with no correlation to mortality [1].

Conservative approach is successful in only 39.3% of patients. The use of proteolytic enzymes has not been previously mentioned, and it did not affect hematoma size at two months, probably due to initial size (greater than 1000 cc). When evacuation is required surgery is performed in 27.9% of patients, while percutaneous drainage is implemented in 22.95% of subjects. Embolization is the least frequent option, indicated in only 8.2% of patients. Either large hematomas may be candidates for non-operative management [8,11] or small sizes lesions may necessitate exploratory laparotomy [12]. Therefore, we propose extrapolating liver trauma classification and treat accordingly based on extension/depth, hemodynamic status, and angiothomography result to discard positive blush [13], as well as signs of liver failure or compression symptoms. Currently, there are insufficient data to determine the safety of conservative management in the setting of an additional indication for surgery or the appropriate time for cholecystectomy. Mirizzi syndrome has not been reported in previous cases, and the presence of a hematoma may difficult cholecystectomy.

In addition to the risk of rupture, sepsis is also a concern. Antibiotics are used and recommended by most authors (70.9%)[1,14], with Pivetta et al being the only to specify the agents used (ciprofloxacin and metronidazole) [1]. The isolated microorganisms in the reports that mentioned cultures were Citrobacter freundii and Escherichia coli, which is consistent with the microbiology of biliary tract infections described in the 2018 Tokyo guidelines [15]. As a result, antimicrobial agents should be selected based on these recommendations.