Patients routinely undergo intravenous sedation, which increases the risk of cardiopulmonary complications, 6, 15. Pdf endoscopic retrograde cholangiopancreatography ercp has. During balloon sweepings the scope snapped and hit the duodenal wall opposite to the ampullary area. The most common complication is postercp pancreatitis, which occurs in. The incidence of perforation post ercp has been investigated by howard et al, who performed a retrospective analysis of 6040 ercps. A clinical and biochemical diagnosis of post ercp pancreatitis and a ct abdopelvis was requested. A doctor from the gastrointestinal surgery department suspected postercp type ii duodenal perforation and decided to continue conservative management. Three out of the six total perforation cases, including the single case of endoscoperelated duodenal injury, were surgically treated. Only two patients required operation and the results of surgery are presented in table iv. The other six perforations were diagnosed by plain xray of the abdomen or ct scan for post ercp abdominal pain. Here, we report a case of ercpinduced duodenal perforation successfully treated with endoscopic pursestring suture. Using the 4hour post ercp amylase level to predict post ercp pancreatitis. Common bile duct perforation by biliary stents postercp.
Seventyfive percent of esophageal perforations in adults occur during endoscopy, 41. Management of duodenal perforation postendoscopic retrograde. Chest and abdominal radiographs are useful in assessing postercp complications. Endoscopic retrograde cholangiopancreatographyrelated perforation 18144 int j clin exp med 2016. Postercp, cbd perforations are relatively rare with the incidence ranging from 0. Two perforations were incidentally diagnosed in an asymptomatic patient in.
In patient b the laparoscopic procedure had to be converted to open and ttube inserted via the perforation site. Duodenum perforation an overview sciencedirect topics. 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. The patient was referred to the general surgery intensive care unit. The incidence of postercp complications postercp pancreatitis, hyperamylasemia, and bleeding was higher in patients with jpdd than those without. The abdominal radiographs of 4 patients 36% showed intraabdominal free air. Abdominal ultrasound scan was requested in a single occasion, in which free. Experience in the management of the complication surgical team 4. Perforation of approximately 1 cm is evident in the duodenal wall contralateral to the papilla over a duodenal diverticulum.
We report two cases of duodenal perforations following endoscopic sphincterotomy. The patient presented the following day with abdominal pain. Postendoscopic retrograde cholangiopancreatography. In an attempt to classify postercp duodenal perforation stapfer, et al. Ercprelated perforation can be retroperitoneal duodenal perforation, perforation of the bile duct or free bowel wall perforation of the duodenum fig. Endoscopic retrograde cholangiopancreatography ercp is an invasive. In total, 15 of 29 patients with ercp perforation were operated on. This study evaluated the early management experience of these perforations. Postendoscopic retrograde cholangiopancreatography ercp perforation usually resolves conservatively. Case report of rescue terap for ile duct perforation using.
The patient underwent emergency surgery after which she was admitted to the icu but her evolution was torpid, and she died. The patient was diagnosed with acute cholangitis and choledocholithiasis. The diagnosis of duodenal perforation after ercp is usually based on physical examination findings, fluroscopic imaging and in some cases by computed tomography imaging. In both cases the ttube was clamped on day 5 followed by cholangiogram to confirm no bile leakage prior to taking out the drains. Management of duodenopancreatobiliary perforations after. All reported cases were symptomatic and required antibiotic cover 911. Post ercp, cbd perforations are relatively rare with the incidence ranging from 0. Early clinical and radiographic features have to be used to determine which type of surgical or conservative treatment is indicated.
In 5 patients, duodenal perforation was immediately noticed during the ercp procedure, and in 1 patient the diagnosis was made after routine postercp abdominal radiography. The incidence of perforation reported by recent series ranges from 0. Duodenal perforations are difficult to diagnose during the ercp procedure because they occur in the lateral wall of the duodenum by side view endoscope. Duodenal perforation post ercp is rare, occurring in 1% range 0. Infection cholangitis the rate of postercp cholangitis is 1% or less. 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. Pneumopericardium, pneumomediastinum, pneumoretroperitoneum. Pdf management of duodenal perforation postendoscopic.
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. Retrospective study of duodenal perforations after ercp diagnosed at a tertiary. The majority of cases of perforation post ercp, remote from the papilla oesophageal, gastric, duodenal, require surgery. Post ercp perforation is burdened by a high risk of mortality. Perforation after endoscopic retrograde cholangiopancreatography ercp is a rare complication, but it is associated with significant mortality. We evaluated our experience of managing postercp perforations to help define the role of surgery with percutaneous drainage pcd. Acute iatrogenic perforation during endoscopy is defined as the presence of gas or luminal contents outside the gastrointestinal tract 7.
Perforations during ercp are caused by endoscopic sphincterotomy, placement of biliary or duodenal stents, guidewirerelated causes, and endoscopy itself. Retroperitoneal air after ercp with sphincterotomy. Case discussion perforation of the duodenum is a recognized complication of endoscopic retrograde cholangiopancreatography ercp. Chest and abdominal radiographs are useful in assessing post ercp complications. This rapid clinical improvement would not be expected in the case of a duodenal perforation by the duodenoscope. The absence of pneumoperitoneum in patients postercp with acute abdomen does not refute a perforation. In particular, perforation of the medial or lateral duodenal wall usually requires. If cannulation of the biliary tree is difficult, a. In an attempt to classify post ercp duodenal perforation stapfer, et al. Endoscopic retrograde cholangiopancreatography ercp related perforations are a rare but serious complication. The diagnosis of postercp perforations are difficult and localization of the perforation can lead to.
Case presentation case 1 a 72yearold male suffering from right upper abdominal pain and fever for 1 day was admitted to the hospital. Advanced endoscopic technology should be considered early diagnosis of postercp perforation, when performed during ercp, or. Although the management of perforation after ercp est is still controversial, a selective management is proposed, based on the features of classification type. The incidence of perforation postercp has been investigated by howard et al, who performed a retrospective analysis of 6040 ercps. Surgical management of duodenal perforations after ercp. Duodenal perforation is an uncommon complication of endoscopic retrograde cholangiopancreatography ercp and a rare complication of upper gastrointestinal endoscopy. Ercpinduced duodenal perforation successfully treated. A 42yearold lady with abdominal pain, gallstones and obstructive jaundice underwent an endoscopic retrograde cholangiopancreatography ercp and sphincterotomy for relief of her symptoms. Endoscopic retrograde cholangiopancreatography ercprelated perforations are a rare but serious complication.
Other complications of ercp are those related to endoscopy and include esophageal, liver, and splenic injury. Vs the risk of a perforation occurring during an ercp is fairly uncommon. Method recent literature in english language from the year 2000 onwards, containing major studies of 9 or more cases on duodenal perforation post ercp were analyzed. Perforation is one of the most dreaded complications of ercp. Some advocate a nonsurgical approach to management in certain select patients. Retroperitoneal duodenal perforation is the most common, often occurring after a sphincterotomy extends past the intramural portion of the bile duct.
Aggressive surgical intervention provides the highest chance for successful outcome, once duodenal perforation has been established. Between november 2003 and december 2011, a total of 8504 ercps were performed at our regional endoscopy center. Successful endoscopic vacuum therapy with new openpore film drainage in a case of iatrogenic duodenal perforation during ercp. Although the management of perforation after ercpest is still controversial, a selective management is proposed, based on the features of classification type. In stable patients, conservative management of duodenal perforation postercp is preferred. Half of patients can be treated conservatively, but in case of sepsis or unstable general conditions, early surgical procedure is indicated as the. The most common sites are the distal esophagus and adjacent to the cricopharyngeus, 41. Imageguided percutaneous management of duodenal perforation following endoscopic retrograde cholangiopancreatography ercp. Prediction of pancreatitis following endoscopic retrograde cholangiopancreatography by the 4h post procedure amylase level.
Successful closure of lateral duodenal perforation by endoscopic band ligation after endoscopic clipping failure. Retroperitoneal duodenal perforation is the most common, often occurring after a sphincterotomy extends past the intramural portion of. Conservative management of duodenal perforation following. In stable patients, conservative management of duodenal perforation post ercp is preferred. The diagnosis of duodenal perforation after ercp is gener ally based on.
Surgical or endoscopic management for postercp large. Early diagnosis of duodenal perforation is essential for an optimum outcome, and subcutaneous emphysema may be a sensitive sign. It can be a result of both intraperitoneal duodenal perforation 30 and retroperitoneal duodenal perforation 29. 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. However, recently several reports indicate the identification of perforation by direct vision. The absence of pneumoperitoneum in patients post ercp with acute abdomen does not refute a perforation. A few perforations however result in lifethreatening retroperitoneal necrosis and require surgical intervention. Iatrogenic duodenal injuries suny downstate medical center. Management of duodenal perforation after endoscopic retrograde.
Mar 05, 2015 a middle aged man with cbd stones, ercp done. Management of perforation after endoscopic retrograde. Sep 21, 2008 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. The patient remained hospitalized with a diagnosis of postercp and sphincterotomy duodenal perforation.
Most are minor perforations that settle with conservative management. The timing of diagnosis is critical for management and patient outcome 810. The group demonstrated that, of the 2874 patients 48% who had a sphincterotomy, 40 patients 0. Duodenal perforation, damage to common bile duct or ampulla of vater. 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. Ct scan is the investigation of choice in these patients.
The treatment of these perforations should still be discussed. 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. 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. Radiology ruled out the presence of subphrenic air, however, a cat scan of the abdomen revealed retroperitoneal air, but not collections or free fluid. However, an increased risk of perforation is seen in patients with sphincter of oddi dysfunction, patients who are undergoing extensions of prior sphincterotomies, and. N2 iatrogenic duodenal and pancreaticobiliary perforations associated with endoscopic retrograde cholangiopancreatography ercp are rare but associated with a significant morbidity and mortality. In the unknown group, only one perforation was identified during ercp. 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.
It extends from the fourth lumbar vertebra to the level of the aorta. Materials and methods between march 2003 and march 20, 2,071 ercps were performed in our hospital. The most frequent post ercp perforation was stapfer type ii 177 patients, 58. Retrospective study of duodenal perforations after ercp diagnosed at a tertiary level hospital, between 2001 and 2011. Clinical and radiographic features of ercprelated periduodenal perforations. 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. Early management experience of perforation after ercp. Duodenal perforation secondary to migration of endobiliary. It is generally agreed that some ercprelated perforations can be successfully managed without surgery 8,9,10,11. Treatment results of gastrointestinal perforation after. There are various clinical courses and presentations of postercp duodenal perforations depending on the extent of the perforation. Due to the discrete nature of the symptoms and the absence of signs of peri. Early diagnosis and prompt treatment of duodenal perforation post ercp, is the. Management of duodenal perforation after endoscopic.
Several different classifications for ercpperforations have been reported in the literature. This has led some authors to recommended early operation in all duodenal perforations. Management of ercprelated small bowel perforations. Nevertheless, duodenal and biliary drainage is essential. An elevation in the serum amylase concentration is common after endoscopic retrograde cholangiopancreatography ercp, occurring in up to 75 percent of patients. Duodenal perforations secondary to a migrated biliary. Evidencebased strategies are lacking regarding the appropriate management of duodenal perforations complicating endoscopic retrograde cholangiopancreatography ercp combined with endoscopic sphincterotomy es. Advanced endoscopic technology should be considered early diagnosis of post ercp perforation, when performed during ercp, or in the recovery room. 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. Postercp perforation is burdened by a high risk of mortality. Hemoclip repair of a sphincterotomyinduced duodenal perforation.
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. Also the routine use of sedation during the procedure makes the diagnosis even more difficult because it masks the symptoms 4, 8, 10. Ercprelated perforations in the new millennium sage journals. Original article influence of juxtampullary duodenal. Iatrogenic duodenal perforation associated with endoscopic retrograde cholangiopancreatography ercp is a very uncommon complication that is often lethal. Pneumothorax is a serious but rare complication of ercp 2831.
The diagnosis of a duodenal perforation is usually made at ercp by a limited contrast study through the endoscope. Endoscopic treatment of a large duodenal perforation. Methods of reducing post ercp pancreatitis patient selection appropriate patient selectionis instrumental inreducing the incidence of pep. There are various clinical courses and presentations of post ercp duodenal perforations depending on the extent of the perforation. 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. Eleven of our fourteen perforations 79% were suspected at the time of ercp.
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