Pneumoretroperitoneum after ERCP sphincterotomy

Case contributed by Adriana Dubbeldam


Recurrent biliary colic without fever. Cholecystectomy was performed 10 years ago, complicated by peritonitis and a 3-month hospitalization.

Patient Data

Age: 65 years
Gender: Female

Note: This case has been tagged as "legacy" as it no longer meets image preparation and/or other case publication guidelines.

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 an 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.

Three days later


CT scan with contrast three days post-sphincterotomy shows a large collection of retroperitoneal air bubbles, as seen around the right kidney and between the pancreas and duodenum.

However, the patient returned to the emergency department two weeks later with malaise and vomiting. Infectious parameters were elevated. CT scan shows a pronounced inflammation of the pancreatic head as well as multiple retroperitoneal abscesses 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 abscesses, however, the scan revealed (not shown) a significant decrease of the volume of these abscesses with no expected benefit of drainage.

Three weeks later


CT scan with contrast three weeks later shows an enlargement of the pancreas head with prominent peripancreatic fat infiltration, consistent with pancreatitis. The pneumoretroperitoneum is fully resorbed. Multiple retroperitoneal abscesses on a more caudal level.

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 of 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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