Major complications of ERCP include pancreatitis, hemorrhage, cholangitis, and duodenal perforation. The occurrence of post-ERCP pneumoperitoneum is a rare event (< 1%), which is usually the result of duodenal or ductal perforation related to therapeutic ERCP with sphincterotomy.
A report article to be published on May 14, 2008 in the World Journal of Gastroenterology reported an extremely rare case of post-ERCP pneumoperitoneum caused by rupture of intrahepatic bile ducts and Glisson's capsule in the area of a large peripheral hepatic metastasis. The potential mechanism for this complication might have been post-ERCP pneumobilia and increased intrahepatic bile ducts pressure leading to rupture of intrahepatic bile ducts of the liver metastatic mass owing to neoplastic tissue friability.
Although there is data on the conservative or surgical management of duodenal perforations complicating ERCP, there is no previous experience on such an unusual complication. There are only scarce reports in the literature of benign pneumoperitoneum after endoscopic biliary procedures that have been successfully managed with conservative treatment. The authors managed the patient conservatively, under close clinical surveillance, based on the absence of (1) peritonitis, (2) sepsis, (3) significant contrast medium leak on ERCP or follow-up upper gastrointestinal study and (4) retro- or intraperitoneal fluid collections on computed tomography. Conservative treatment consisted of no oral intake, nasogastric drainage, intravenous fluid replacement, analgesics and systemic broad-spectrum antibiotics. The patient had finally a successful outcome without need for surgical intervention.
With this case report, the authors point towards the need for close clinical and radiological observation of patients with hepatic masses (primary or metastatic) subjected to ERCP. They suggest that avoidance of excessive air insufflation during ERCP and/or placement of a nasogastric tube for bowel decompression immediately after ERCP might be a reasonable strategy to prevent such unusual complications.
World Journal of Gastroenterology