Vision loss: another ERCP-related adverse event, also known as isolated bilateral lateral geniculate body infarction

Abstract

A 22-year-old healthy woman experienced intermittent epigastric pain 3 weeks after an uncomplicated pregnancy. Cholecystitis was diagnosed on the basis of US, and cholecystectomy was scheduled in 2 weeks. Because of the persistence of intermittent pain and mild laboratory evidence of cholestasis, with bilirubin total of 1.6 mg/dL, the patient underwent preoperative ERCP because of a concern for choledocholithiasis, despite normal common bile duct (CBD) on US (A) and no symptoms of cholangitis. ERCP with precut sphincterotomy to facilitate CBD cannulation and subsequent balloon-sweep revealed a normal cholangiogram (B). An indomethacin suppository was given. Within 24 hours after ERCP, the patient experienced severe epigastric pain. Acute pancreatitis was diagnosed on the basis of lipase 2200 units/L. Intravenous fluids were started 12 hours later. Simultaneously, the patient experienced rapidly progressing, painless, bilateral vision loss, necessitating transfer to our hospital. Her pain resolved within 72 hours; however, the result of neurologic examination was pertinent for persistent profound bilateral vision loss but was otherwise nonfocal, with normal fundoscopic examination results. Magnetic resonance imaging of the brain revealed bilateral lateral geniculate body infarcts (C). Given the temporal relationship to post-ERCP pancreatitis, a watershed infarction was suspected, likely resulting from temporary hypotension. The result of a comprehensive evaluation for other causes of stroke, including vasculitis and hypercoagulability, was negative. Because potentially severe ERCP-related adverse events can occur, the correct procedure indication is crucial.