Early diagnosis of duodenal perforation is essential for an optimum outcome, and subcutaneous emphysema may be a sensitive sign. It is generally agreed that some ercp related perforations can be successfully managed without surgery 8,9,10,11. Half of patients can be treated conservatively, but in case of sepsis or unstable general conditions, early surgical procedure is indicated as the. Management of duodenal perforation after endoscopic.
Although the management of perforation after ercpest is still controversial, a selective management is proposed, based on the features of classification type. Infection cholangitis the rate of postercp cholangitis is 1% or less. Early diagnosis and prompt treatment of duodenal perforation post ercp, is the. When the ercp images shown above are inverted, free air in the right retroperitoneal compartment is more easily identified as bubbly lucency adjacent to the vertebral column. Duodenal perforation post ercp is rare, occurring in 1% range 0. Radiology ruled out the presence of subphrenic air, however, a cat scan of the abdomen revealed retroperitoneal air, but not collections or free fluid. Endoscopic retrograde cholangiopancreatography ercp is an invasive. Perforation is one of the most dreaded complications of ercp. The diagnosis of duodenal perforation after ercp is gener ally based on. The majority of cases of perforation post ercp, remote from the papilla oesophageal, gastric, duodenal, require surgery. Iatrogenic duodenal injuries suny downstate medical center. The most frequent post ercp perforation was stapfer type ii 177 patients, 58. Ct scan showed aerobilia and free fluid in the peritoneum that extended from the lower edge of the liver to the space anterior to the right kidney figure 1. Early management experience of perforation after ercp.
Retroperitoneal duodenal perforation is the most common, often occurring after a sphincterotomy extends past the intramural portion of. Management of duodenopancreatobiliary perforations after. Clinical and radiographic features of ercprelated periduodenal perforations. Ercp in one case and, in the second case, perforation was evident during ercp and a biliary stent was inserted. In an attempt to classify postercp duodenal perforation stapfer, et al. Ercpinduced duodenal perforation successfully treated. The patient remained hospitalized with a diagnosis of postercp and sphincterotomy duodenal perforation. Chest and abdominal radiographs are useful in assessing post ercp complications. Pneumopericardium, pneumomediastinum, pneumoretroperitoneum. Patients lie in the left lateral decubitus position for introduction of the endoscope into the duodenum and are then turned into the prone oblique position, 16. Materials and methods between march 2003 and march 20, 2,071 ercps were performed in our hospital. Duodenal perforation secondary to migration of endobiliary. Managing perforations related to endoscopic retrograde.
In stable patients, conservative management of duodenal perforation post ercp is preferred. Perforation after endoscopic retrograde cholangiopancreatography ercp is a rare complication, but it is associated with significant mortality. The absence of pneumoperitoneum in patients post ercp with acute abdomen does not refute a perforation. Several different classifications for ercpperforations have been reported in the literature. The patient was referred to the general surgery intensive care unit.
Post ercp perforation is burdened by a high risk of mortality. Common bile duct perforation by biliary stents postercp. An elevation in the serum amylase concentration is common after endoscopic retrograde cholangiopancreatography ercp, occurring in up to 75 percent of patients. It extends from the fourth lumbar vertebra to the level of the aorta.
In both cases the ttube was clamped on day 5 followed by cholangiogram to confirm no bile leakage prior to taking out the drains. This rapid clinical improvement would not be expected in the case of a duodenal perforation by the duodenoscope. Evidencebased strategies are lacking regarding the appropriate management of duodenal perforations complicating endoscopic retrograde cholangiopancreatography ercp combined with endoscopic sphincterotomy es. The treatment of these perforations should still be discussed. Pdf endoscopic retrograde cholangiopancreatography ercp has. A clinical and biochemical diagnosis of post ercp pancreatitis and a ct abdopelvis was requested. Gas bubbles along the falciform ligament falciform ligament sign and in the intrahepatic fissure of ligamentum teres ligamentum teres sign are useful predictors of intraperitoneal gastroduodenal perforation 3, 5, 8, 10, 12. The incidence of perforation postercp has been investigated by howard et al, who performed a retrospective analysis of 6040 ercps. In particular, perforation of the medial or lateral duodenal wall usually requires.
Endoscopic retrograde cholangiopancreatographyrelated perforation 18144 int j clin exp med 2016. Ercprelated perforation can be retroperitoneal duodenal perforation, perforation of the bile duct or free bowel wall perforation of the duodenum fig. Ct scan is the investigation of choice in these patients. Endoscopy shows a high sensitivity and specificity for diagnosis of iatrogenic perforation 11. Three out of the six total perforation cases, including the single case of endoscoperelated duodenal injury, were surgically treated. However, recently several reports indicate the identification of perforation by direct vision. Methods of reducing post ercp pancreatitis patient selection appropriate patient selectionis instrumental inreducing the incidence of pep. The patient was diagnosed with acute cholangitis and choledocholithiasis.
Management of duodenal perforation postendoscopic retrograde. The timing of diagnosis is critical for management and patient outcome 810. N2 iatrogenic duodenal and pancreaticobiliary perforations associated with endoscopic retrograde cholangiopancreatography ercp are rare but associated with a significant morbidity and mortality. Mar 05, 2015 a middle aged man with cbd stones, ercp done. Retrospective study of duodenal perforations after ercp diagnosed at a tertiary. Two perforations were incidentally diagnosed in an asymptomatic patient in. We evaluated our experience of managing postercp perforations to help define the role of surgery with percutaneous drainage pcd. The patient presented the following day with abdominal pain. Duodenal perforation, damage to common bile duct or ampulla of vater. In an attempt to classify post ercp duodenal perforation stapfer, et al. Successful endoscopic vacuum therapy with new openpore film drainage in a case of iatrogenic duodenal perforation during ercp. Advanced endoscopic technology should be considered early diagnosis of post ercp perforation, when performed during ercp, or in the recovery room.
Duodenum perforation an overview sciencedirect topics. The incidence of postercp complications postercp pancreatitis, hyperamylasemia, and bleeding was higher in patients with jpdd than those without. Duodenal perforations secondary to a migrated biliary. Most are minor perforations that settle with conservative management. Retroperitoneal air after ercp with sphincterotomy. The abdominal radiographs of 4 patients 36% showed intraabdominal free air. The absence of pneumoperitoneum in patients postercp with acute abdomen does not refute a perforation. Experience in the management of the complication surgical team 4. Post ercp, cbd perforations are relatively rare with the incidence ranging from 0. Introduction after successful medical management of a patient with a clinical picture suggestive of post sphincterotomy duodenal perforation, and in which the computed axial tomography ct scan of the abdomen revealed the presence of subcutaneous emphysema and retroperitoneal air, there was concern about the frequency of post ercp with sphincterotomy. Conservative management of duodenal perforation following.
The incidence of perforation reported by recent series ranges from 0. Surgical management of duodenal perforations after ercp. The other six perforations were diagnosed by plain xray of the abdomen or ct scan for post ercp abdominal pain. Surgical or endoscopic management for postercp large. Pdf management of duodenal perforation postendoscopic. The most common sites are the distal esophagus and adjacent to the cricopharyngeus, 41. Duodenal perforation is an uncommon complication of endoscopic retrograde cholangiopancreatography ercp and a rare complication of upper gastrointestinal endoscopy. Early clinical and radiographic features have to be used to determine which type of surgical or conservative treatment is indicated. Acute iatrogenic perforation during endoscopy is defined as the presence of gas or luminal contents outside the gastrointestinal tract 7. It can be a result of both intraperitoneal duodenal perforation 30 and retroperitoneal duodenal perforation 29. Prediction of pancreatitis following endoscopic retrograde cholangiopancreatography by the 4h post procedure amylase level. Eleven of our fourteen perforations 79% were suspected at the time of ercp. In patient b the laparoscopic procedure had to be converted to open and ttube inserted via the perforation site.
This study evaluated the early management experience of these perforations. Nevertheless, duodenal and biliary drainage is essential. Ercprelated perforations in the new millennium sage journals. Successful closure of lateral duodenal perforation by endoscopic band ligation after endoscopic clipping failure. During balloon sweepings the scope snapped and hit the duodenal wall opposite to the ampullary area. All reported cases were symptomatic and required antibiotic cover 911. Retroperitoneal duodenal perforation is the most common, often occurring after a sphincterotomy extends past the intramural portion of the bile duct. Vs the risk of a perforation occurring during an ercp is fairly uncommon. Retrospective study of duodenal perforations after ercp diagnosed at a tertiary level hospital, between 2001 and 2011. Endoscopic retrograde cholangiopancreatography ercprelated perforations are a rare but serious complication. This has led some authors to recommended early operation in all duodenal perforations.
Advanced endoscopic technology should be considered early diagnosis of postercp perforation, when performed during ercp, or. The incidence of perforation post ercp has been investigated by howard et al, who performed a retrospective analysis of 6040 ercps. Endoscopic retrograde cholangiopancreatography ercp related perforations are a rare but serious complication. Aggressive surgical intervention provides the highest chance for successful outcome, once duodenal perforation has been established. Chest and abdominal radiographs are useful in assessing postercp complications.
If cannulation of the biliary tree is difficult, a. A doctor from the gastrointestinal surgery department suspected postercp type ii duodenal perforation and decided to continue conservative management. Also the routine use of sedation during the procedure makes the diagnosis even more difficult because it masks the symptoms 4, 8, 10. During ercp, fluoroscopy revealed abnormal perinephric gas shadowing after breaking and extracting the stones. Albeit the use of fcsems is widely recommended as one of the endoscopic treatment options as an expert opinion in iatrogenic endoscoperelated duodenal free wall perforations, 123 4 this. A few perforations however result in lifethreatening retroperitoneal necrosis and require surgical intervention. However, an increased risk of perforation is seen in patients with sphincter of oddi dysfunction, patients who are undergoing extensions of prior sphincterotomies, and. Between november 2003 and december 2011, a total of 8504 ercps were performed at our regional endoscopy center. In total, 15 of 29 patients with ercp perforation were operated on. The group demonstrated that, of the 2874 patients 48% who had a sphincterotomy, 40 patients 0. Management of duodenal perforation after endoscopic retrograde. Seventyfive percent of esophageal perforations in adults occur during endoscopy, 41. There are various clinical courses and presentations of post ercp duodenal perforations depending on the extent of the perforation.
The most common complication is postercp pancreatitis, which occurs in. Some advocate a nonsurgical approach to management in certain select patients. Due to the discrete nature of the symptoms and the absence of signs of peri. Other complications of ercp are those related to endoscopy and include esophageal, liver, and splenic injury. Postendoscopic retrograde cholangiopancreatography.
Only two patients required operation and the results of surgery are presented in table iv. Abdominal ultrasound scan was requested in a single occasion, in which free. The diagnosis of a duodenal perforation is usually made at ercp by a limited contrast study through the endoscope. Case presentation case 1 a 72yearold male suffering from right upper abdominal pain and fever for 1 day was admitted to the hospital. The diagnosis of duodenal perforation after ercp is usually based on physical examination findings, fluroscopic imaging and in some cases by computed tomography imaging. Using the 4hour post ercp amylase level to predict post ercp pancreatitis. Postercp perforation management free abdominal duodenal perforations usually require surgery conservative approach to retroperitoneal perforation following sphincterotomy has been adopted early surgical consultation and careful observation is mandatory outcome poor in patients who do not receive prompt and appropriate treatment. A 42yearold lady with abdominal pain, gallstones and obstructive jaundice underwent an endoscopic retrograde cholangiopancreatography ercp and sphincterotomy for relief of her symptoms. The variables age, sex, ercp indication, type of perforation, time of diagnosis, clinical presentation, radiographic findings, management, surgical technique, length of stay and intrahospital mortality were recorded and analyzed. Horizontal duodenal perforation, abdominal trauma, ercp related perforation background injury to the horizontal part of the duodenum is relatively rare because of the presence of retroperitoneal space 1. Sep 21, 2008 early diagnosis of duodenal perforation is essential for an optimum outcome, and subcutaneous emphysema may be a sensitive sign. Patients routinely undergo intravenous sedation, which increases the risk of cardiopulmonary complications, 6, 15. The patient underwent emergency surgery after which she was admitted to the icu but her evolution was torpid, and she died.
Introduction after successful medical management of a patient with a clinical picture suggestive of post sphincterotomy duodenal perforation, and in which the computed axial tomography ct scan of the abdomen revealed the presence of subcutaneous emphysema and retroperitoneal air, there was concern about the frequency of post ercp with sphincterotomy pneumoretroperitoneum and if any procedure. In stable patients, conservative management of duodenal perforation postercp is preferred. Eus and mrcp are equivalent to ercp for the detection of some pancreaticobiliary disorders such as choledocholithiasis but lack the risk of pancreatitis associated with ercp. Iatrogenic duodenal perforation associated with endoscopic retrograde cholangiopancreatography ercp is a very uncommon complication that is often lethal. Perforation of approximately 1 cm is evident in the duodenal wall contralateral to the papilla over a duodenal diverticulum. Pneumothorax is a serious but rare complication of ercp 2831.
Management of perforation after endoscopic retrograde. Postercp, cbd perforations are relatively rare with the incidence ranging from 0. Postercp perforation is burdened by a high risk of mortality. Perforations during ercp are caused by endoscopic sphincterotomy, placement of biliary or duodenal stents, guidewirerelated causes, and endoscopy itself. Postendoscopic retrograde cholangiopancreatography ercp perforation usually resolves conservatively. Case report of rescue terap for ile duct perforation using. Here, we report a case of ercpinduced duodenal perforation successfully treated with endoscopic pursestring suture. Imageguided percutaneous management of duodenal perforation following endoscopic retrograde cholangiopancreatography ercp. In the unknown group, only one perforation was identified during ercp. It is generally agreed that some ercprelated perforations can be successfully managed without surgery 8,9,10,11.
Case discussion perforation of the duodenum is a recognized complication of endoscopic retrograde cholangiopancreatography ercp. Duodenal perforations are difficult to diagnose during the ercp procedure because they occur in the lateral wall of the duodenum by side view endoscope. There are various clinical courses and presentations of postercp duodenal perforations depending on the extent of the perforation. In 5 patients, duodenal perforation was immediately noticed during the ercp procedure, and in 1 patient the diagnosis was made after routine post ercp abdominal radiography. Although the management of perforation after ercp est is still controversial, a selective management is proposed, based on the features of classification type. The diagnosis of postercp perforations are difficult and localization of the perforation can lead to. Treatment results of gastrointestinal perforation after. Original article influence of juxtampullary duodenal. Endoscopic treatment of a large duodenal perforation.
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