An unusual post-ERCP pneumoperitoneum

Abstract

A 74-year-old man with symptomatic common bile duct stricture secondary to chronic pancreatitis had undergone multiple endoscopic retrograde cholangiopancreatographies (ERCP) with plastic stent placements. The patient refused hepaticojejunostomy and did not present for scheduled stent exchange. He was admitted to the Intensive Care Unit (ICU) with severe acute cholangitis and septic shock eighteen months after the last stent exchange. Urgent ERCP showed biliary stent migration with biliary dilation and multiple stones over the stricture (Fig. 1a ). Stones were extracted with a Dormia basket and a partially covered SEMS (Wallflex, Boston Scientific) and naso-biliary drain were placed to drain purulent bile (Fig. 1b). Six hours after ERCP a chest X-ray showed subdiaphragmatic free air. Computed tomography (CT) showed hepatic abscess in the 3rd hepatic segment, pneumoperitoneum with rupture of the Glisson's capsule and communication with intra-abdominal air (Fig. 2-arrow ). The air inflated during ERCP from the duodenum had reached the abdominal cavity, through the abscess communicating with the biliary tree. Four days later, a CT showed complete pneumoperitoneum regression. Hepatic abscess was subsequently drained percutaneously, septic shock resolved, and the patient was discharged twenty days after ERCP. A similar case was described in a patient with hepatic metastases from pancreatic cancer [ [1] Assimakopoulos S.F. Thomopoulos K.C. Giali S. et al. A rare etiology of post-endoscopic retrograde cholangiopancreatography pneumoperitoneum. World J Gastroenterol. 2008; 14: 2917-2919 Crossref PubMed Scopus (9) Google Scholar ]. The present case describes an unusual post-ERCP pneumoperitoneum in a patient with a benign disease, that resolved spontaneously. Fig. 2 View Large Image Figure Viewer Download Hi-res image