Tension Pneumoperitoneum: A Rare Complication after Endoscopic Retrograde Cholangiopancreatography

Abstract

Endoscopic retrograde cholangiopancreatography (ERCP), a minimally invasive endoscopic procedure, is widely used for diagnosis and treatment of hepatobiliary tract and pancreatic diseases ( 1 Schröder A.S. Heinemann A. Nushida H. Sperhake J.P. Fatal pneumoperitoneum following endoscopic retrograde cholangiopancreatography confirmed by post-mortem computed tomography. Forensic Sci Med Pathol. 2015; 11: 460-463 Crossref PubMed Scopus (3) Google Scholar ). Viscus perforation is a rare complication of ERCP, with a reported incident rate of 0.35–1.6%, but its mortality is quite high ( 2 Miller R. Zbar A. Klein Y. et al. Perforations following endoscopic retrograde cholangiopancreatography: a single institution experience and surgical recommendation. Am J Surg. 2013; 206: 180-186 Abstract Full Text Full Text PDF PubMed Scopus (38) Google Scholar ). There are few cases in the literature, reporting tension pneumoperitoneum (TP) as a complication of ERCP ( 1 Schröder A.S. Heinemann A. Nushida H. Sperhake J.P. Fatal pneumoperitoneum following endoscopic retrograde cholangiopancreatography confirmed by post-mortem computed tomography. Forensic Sci Med Pathol. 2015; 11: 460-463 Crossref PubMed Scopus (3) Google Scholar , 2 Miller R. Zbar A. Klein Y. et al. Perforations following endoscopic retrograde cholangiopancreatography: a single institution experience and surgical recommendation. Am J Surg. 2013; 206: 180-186 Abstract Full Text Full Text PDF PubMed Scopus (38) Google Scholar , 3 Ozgonul A. Cece H. Sogut O. Demir D. Kurkcuoglus I.C. Pneumoperitoneum, pneumoretroperitoneum and bilateral pneumothorax caused by ERCP. J Pak Med Assoc. 2010; 60: 60-61 PubMed Google Scholar ). Most case reports of TP describe this life-threatening condition after colonoscopy ( 4 Kaafarani H.M. Tension pneumoperitoneum. N Engl J Med. 2015; 373: e24 Crossref PubMed Scopus (3) Google Scholar , 5 Lin B.W. Thanassi W. Tension pneumoperitoneum. J Emerg Med. 2010; 38: 57-59 Abstract Full Text Full Text PDF PubMed Scopus (16) Google Scholar , 6 Villafáñez-García M.C. San Gil J.G. Ortega-Abengozar H. Pérez-Roldán F. Massive pneumoperitoneum after colonoscopy. J Emerg Med. 2012; 42: 58-59 Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar , 7 Yakobi-Shvili R. Cheng D. Tension pneumoperitoneum—a complication of colonoscopy: recognition and treatment in the emergency department. J Emerg Med. 2002; 22: 419-420 Abstract Full Text Full Text PDF PubMed Scopus (18) Google Scholar ). TP is also the result of improper cardiopulmonary resuscitation, positive pressure ventilation, and obstipation ( 8 Campillo-Soto A. Liron-Ruiz R. Torralba-Martinez J.A. Morales- Cuenca G. del Pozo P. Aguayo-Albasini J.L. Gastric rupture and massive pneumoperitoneum after cardiopulmonary resuscitation by lay persons. Cir Esp. 2007; 81 ([in Spanish]): 49-51 Crossref PubMed Scopus (7) Google Scholar , 9 ONeil A.M. Sztajnkrycer M.D. Elderly man with abdominal pain and shortness of breath. Ann Emerg Med. 2016; 67: 70 Abstract Full Text Full Text PDF Scopus (2) Google Scholar , 10 Miller D. Tension pneumoperitoneum caused by obstipation. West J Emerg Med. 2015; 16: 777-780 Crossref PubMed Scopus (6) Google Scholar ). Like tension pneumothorax, the diagnosis is basically clinical, and prompt diagnosis is necessary to provide a timely life-saving intervention ( 5 Lin B.W. Thanassi W. Tension pneumoperitoneum. J Emerg Med. 2010; 38: 57-59 Abstract Full Text Full Text PDF PubMed Scopus (16) Google Scholar ). It should be considered in any patient presenting with signs of circulatory shock and a distended, tense abdomen ( 7 Yakobi-Shvili R. Cheng D. Tension pneumoperitoneum—a complication of colonoscopy: recognition and treatment in the emergency department. J Emerg Med. 2002; 22: 419-420 Abstract Full Text Full Text PDF PubMed Scopus (18) Google Scholar ). There are several radiologic signs for massive pneumoperitoneum, which will be discussed. Here we present a case of TP after ERCP.