Retroperitoneal Abscess Presenting as an Incidental Finding Post Endoscopic Retrograde Cholangiopancreatography (ERCP)

Abstract

Background: ERCP is a well-recognized tool in the managment of choledocholithiasis. However, even with careful patient selection, complications happen. Among ERCP complications, perforation represents one of the most feared events at a rate of 0.5-2.1%. We report a case of 90-year-old female status post ERCP 3 weeks prior to admission, that presented with shortness of breath and was found to have an incidental retroperitoneal abscess on radiological imaging. Case Report: An 89-year-old female with past medical history of hypertension, presented with shortness of breath for four days. She underwent ERCP with sphincterotomy, mechanical lithotripsy and stent placement for choledocholithiasis. On admission, she was afebrile and tachycardic without abdominal pain. Physical examination revealed bilateral decreased breath sounds, coarse crackles and jugular venous distention. Laboratory values showed elevated liver enzymes (AST- 73 IU/L and ALT- 21 IU/L). Computed tomography (CT scan) of chest with contrast showed pulmonary emboli (PE) with moderate to large pericardial effusion with possible right heart strain. She was started on intravenous heparin drip for PE. Pericardiocentesis with pericardial biopsy was performed. Pericardial biopsy was positive for large B-cell lymphoma. Enhanced abdominal CT scan demonstrated an incidental finding of right-sided retroperitoneal abscess measuring 5.5 x 5.5 x 5.7 cm in dimension. Upper gastrointestinal series found no gross abnormalities of the stomach and duodenal bulb. One day after admission she developed a temperature of 100.8 F and was started on antibiotics. CT guided percutaneous drainage was performed with placement of right sided pigtail catheter. Gram stain and culture of fluid drained from retroperitoneal abscess did not grow any bacteria, since antibiotics were started prior to the draining of abscess. She completed six days course of antibiotics with complete resolution of symptoms. Discussion: Retroperitoneal abscess is a rare complication post ERCP most likely secondary to focal perforation and transmigration of bacteria. Patients could be asymptomatic or septic depending on the size of perforation and location of abscess. Early identification and treatment can lead to improved survival and better outcomes in patients with post ERCP complications.Figure 1Figure 2Figure 3