Successful Treatment of Pneumomediastinum, Pneumothorax, Pneumoperitoneum, Pneumoretroperitoneum, and Subcutaneous Emphysema Following ERCP without Surgery

Abstract

Purpose: We present a case of pneumomediastinum, pneumothorax, pneumoperitoneum, pneumoretroperitoneum, and subcutaneous emphysema following an ERCP. Methods: A 73-year old female with prior cholecystectomy, gastroduodenostomy and choledocoduodenostomy in childhood presented with jaundice, abdominal pain, elevated LFTs, and dilated bile ducts on abdominal CT. Percutaneous cholangiography (PTC) revealed an anastomostic stricture of the bile duct remnant at its junction with a pseudodiverticulum of the duodenal wall. After temporary percutaneous biliary decompression, a second PTC performed stricture dilation, external-internal biliary stent placement, and biliary brushings, for which pathology was benign. The stricture was thought to be benign and a result of chronic duodenal-biliary reflux. Nonsurgical management was pursued with a combined PTC-ERCP procedure that dilated the stricture and placed dual biliary stents. Two months later, she underwent a second ERCP for further treatment of the stricture. During ERCP, the patient had extraction of the previously placed stents, biliary brushings, balloon dilation, and quadruple stent placement. In the recovery room, she developed chest pain and dyspnea. Physical exam had decreased heart and breath sounds, and extensive crepitus. Chest and abdomen x-rays revealed pneumomediastinum, pneumothorax, retroperitoneal and intraperitoneal air, and subcutaneous emphysema. Supplemental oxygen and IV Zosyn® were administered, and bilateral chest tubes were placed. Esophagogram, chest and abdomen CT, and laryngoscopy were performed to evaluate for a site of perforation, which was not found. The chest tubes were removed after 3 days, diet advanced, and the patient was discharged uneventfully on day 7. She was seen 2 months later, with no residual symptoms, and will have elective stent removal. Conclusion: ERCP-related perforation is uncommon, but mortality rates are high. There are 4 types, in descending severity: I- duodenal wall (endoscope injury); II- periampullary (injury during sphincterotomy); III- ductal (guidewire injury); and IV- retroperitoneal air only (use of compressed air). Diagnosis requires a high clinical suspicion for early detection to allow optimal management of the perforation and a better prognosis. The site of perforation may be visible and localized with extravasation of air or contrast during ERCP, or may not be visible due to microperforation. Management of type I injury and any patient with signs of peritonitis is immediate surgery. Most others can be managed without surgery using IV antibiotics, NPO, and serial abdominal and radiographic exams, with chest tube placement reserved for those with symptomatic pneumothorax as seen in this case.