Bowel perforation at ERCP

Case contributed by Vikas Shah

Presentation

ERCP for obstructing common bile duct stones.

Patient Data

Age: 55 years
Gender: Female

ERCP

Fluoroscopy

There are cholecystectomy clips. The CBD has been cannulated and a contrast cholangiogram shows intraluminal filling defects consistent with stones. Sphincterotomy and balloon trawl performed and then a biliary stent deployed. Some abdominal pain at end of procedure.

Due to continuing abdominal pain in the recovery period, an urgent medical review was sought and a chest x-ray requested.

Chest x-ray

x_ray

Free air seen under both hemidiaphragms in keeping with pneumoperitoneum.

CT abdomen and pelvis

ct

There is a large pneumoperitoneum and also extensive free gas in the retroperitoneum, extending up to the mediastinum. Free fluid is also present. Biliary stents are noted, and pneumobilia is consistent with the recent sphincterotomy. The duodenum is edematous. Normal appearances of the pancreas.

Inverted ERCP images

Fluoroscopy

When the ERCP images shown above are inverted, free air in the right retroperitoneal compartment is more easily identified as bubbly lucency adjacent to the vertebral column.

Case Discussion

Perforation of the duodenum is a recognized complication of endoscopic retrograde cholangiopancreatography (ERCP). This case illustrates that careful review of the ERCP images may allow earlier identification of complications such as pneumoperitoneum or pneumoretroperitoneum. Inverting the image enables the bubbly lucency of free air in the retroperitoneum to be more easily discerned.

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