Massive subcutaneous emphysema, unilateral pneumothorax, pneumomediastinum and pneumoperitoneum after endoscopic retrograde cholangiopancreatography

In this paper we discuss a case of duodenal perforation resulting in subcutaneous emphysema, left-sided pneumothorax, pneumomediastinum and pneumoperitoneum. Duodenal perforation is a rare, but serious complication of endoscopic retrograde cholangiopancreatography (ERCP). Signs indicating perforation include agitation, tachypnoea, dyspnoea, subcutaneous emphysema or hypoxaemia. Diagnosis can be confirmed by abdominal computed tomography (CT) scan. Treatment is surgical or conservative and based on the type of perforation, clinical status and radiographic imaging. Conservative treatment consists of the administration of oxygen, broad spectrum antibiotic therapy, biliary and duodenal drainage (nasobiliary and/or nasogastric tubes), nil by mouth, and if indicated, with respect to the severity of pneumothorax and hypoxaemia, uni- or bilateral pleural drainage. Frequent re-evaluation of the patient’s clinical condition is warranted.