Pneumoretroperitoneum after ERCP sphincterotomy

Case contributed by Dr Adriana Dubbeldam

Presentation

Patient presented with recurrent biliairy colic without fever. Cholecystectomy was performed 10 years ago, complicated by peritonitis and a 3-month hospitalisation.

Patient Data

Age: 65 years old
Gender: Female
Modality: Fluoroscopy

Standard fluoroscopy during ERCP before and after sphincterotomy

Comparing the radiographs taken just before the sphincterotomy and after shows the sudden presence of free intra-abdominal air, which is not consistent with a intraperitoneal distribution; instead, the air is restricted to the space around the right adrenal gland. Although the amount of free air seems limited, the patient developed progressive pneumoretroperitoneum and a CT was performed.

Because of rising infectious parameters (CRP) and pancreas enzymes, a CT scan was performed three days later.

Patient was initially treated with antibiotics and progress followed with standard radiography. With the suspected development of pancreatitis and fear of retroperitoneal abcess, a CT was performed three days after the perforation, showing only pneumoretroperitoneum and no retroperitoneal abcess. The patient was released home ten days after the ERCP.

However, the patient returned to the emergency department two weeks later with malaisia and vomiting. Infectious parameters were elevated. CT scan shows a pronounced inflammation of the pancreatic head as well as multiple retroperitoneal abcesses on a lower level.

After a week of treatment and further elevating infectious parameters, a new CT was performed for possible drainage of the retroperitoneal abcesses, however, scan revealed (not shown) a significant decrease of the volume of these abcesses with no expected benefit of drainage.

Case Discussion

Small duodenal perforations during ERCP-sphincterotomy are not rare and most perforations cause pneumoretroperitoneum, although pneumoperitoneum is also possible. Often the Radiologist or Resident is the first one to notice and therefore it is their task to detect and warn the physician to this complication. Furthermore, imaging is used to follow-up, to rule out further complications such as abscess formation or pancreatitis, and if needed, to guide abscess drainage.

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Case Information

rID: 22197
Case created: 19th Mar 2013
Last edited: 8th May 2016
Inclusion in quiz mode: Included

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