Chan, FL

Cheung, SCW

Ng, M

Hong Kong Medical Journal

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Title Abdominal pain after endoscopic interventionAuthor(s) Cheung, SCW; Chan, FL; Ng, MCitation Hong Kong Medical Journal, 2001, v. 7 n. 3, p. 281-283Issued Date 2001URL http://hdl.handle.net/10722/225019RightsHong Kong Medical Journal. Copyright © Hong Kong MedicalAssociation.; This work is licensed under a Creative CommonsAttribution-NonCommercial-NoDerivatives 4.0 InternationalLicense.HKMJ Vol 7 No 3 September 2001      281MEDICAL PRACTICEKey words:Bile duct diseases;Cholangiopancreatography,endoscopic retrograde;Intestinal perforation;Retroperitoneal space;Tomography, X-ray computed ! ! !"#$%&'()*+ !" !"# !"#$%&' XAbdominal pain after endoscopicintervention○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○SCW Cheung  FL Chan  M Ng  HKMJ 2001;7:281-3 !"#$%&The University of Hong Kong, Queen MaryHospital, 102 Pokfulam Road, Hong Kong:Department of RadiologySCW Cheung, MRCP, FRCRFL Chan, FRCR, FHKAM (Radiology)Department of MedicineM Ng, FRCP (Edin), FHKAM (Medicine)Correspondence to: Dr SCW CheungQuizA 72-year-old woman presented to the Queen Mary Hospital with a historyof jaundice and pruritus for 2 weeks. Serum investigation revealed a totalbilirubin of 30 mmol/L (normal range, 7-19 mmol/L) and an alkalinephosphatase of 1300 U/L (normal range, 54-140 U/L). Ultrasoundexamination of the liver demonstrated dilatation of the intrahepatic bileducts and proximal common duct. The distal common duct could not befully assessed owing to overlying bowel gas. Endoscopic retrogradecholangiography (ERC) was performed to look for the cause of the biliaryobstruction. A papillary growth was found in the common duct nearthe cystic duct insertion. A plastic biliary stent was inserted aftersphincterotomy.On the day after the ERC, the patient complained of abdominal pain.A plain radiograph was obtained of the abdomen with her in the erectposition (Fig 1). What acute condition is she suffering from?Fig 1. Quiz film282      HKMJ Vol 7 No 3 September 2001Cheung et alAnswerPerforation of duodenum after endoscopic biliaryprocedureFindings on radiographyFigure 1 shows, in addition to a biliary stent, the pres-ence of retroperitoneal air, presenting as a radio-lucent cuff that renders the right renal outline undulyclear. This is typical of the presence of air in the rightpararenal space. In the clinical context of the patientunder discussion, this probably resulted from retro-peritoneal perforation of the duodenum after biliarytract intervention. The second part of the duodenumand the pancreas are both retroperitoneal structureslocated in the anterior pararenal space. Any leakageof their contents, including air, bowel content, orpancreatic enzymes, can track into this space andextend to surround the right kidney. A small amountof intraperitoneal air is also observed under the medialaspect of the right hemidiaphragm on the film. Therewas no extension of the retroperitoneal air into themediastinum and a chest radiograph did not reveal anypneumothorax.Clinical management and progressApart from some abdominal pain, the patient waslargely asymptomatic, with no signs of sepsis orperitonitis. She was treated conservatively withparenteral nutrition and prophylactic antibiotics. Sheremained afebrile throughout, and leucocytosis wasnot observed on serial blood sampling. She wasdischarged after 10 days of uneventful in-patientmanagement. For the original biliary pathology, theplan was surgical resection of the bile duct tumourand hepaticojejunostomy.Perforation of bile duct and gastrointestinaltract after endoscopic retrogradecholangiopancreatographyLike any endoscopic procedure, ERC with biliary inter-vention carries with it a risk of perforating the gastro-intestinal tract. Oesophageal or gastric perforation isvery rare. Duodenal or bile duct perforation occurs inabout 1% of cases, and has an associated mortality rateof up to 18%. Unrecognised perforation at the time ofthe procedure runs an even greater risk of death, makingprompt and accurate diagnosis of this complicationvery important indeed.The cause of perforation varies. It may be causedby the scope, the guide wire, the sphincterotome, orinsertion of the endoprosthesis (stent).1 It occurs morecommonly in interventional (as opposed to diagnostic)procedures, although this is not agreed universally.The site of perforation also varies. Lateral duodenalwall perforation is usually caused by the scope, islarge, and frequently requires surgical intervention.Perforation of the medial wall or the lower commonduct, on the other hand, is often smaller, is associatedwith fewer symptoms, and is sometimes amenable toconservative management.In many cases, the endoscopist can visualise theperforation during endoscopic retrograde cholangio-pancreatography (ERCP). Perforations can, however,be mistaken for duodenal diverticula or fistula, and bemissed initially. If a perforation is suspected, contrastmaterial can be injected via the scope to look forleakage. Large leakages are usually associated withpersistent contrast pooling around the duodenum,whereas the contrast tends to disperse more quicklywith smaller leakages. In this case, the perforation wasdetected when the fluoroscopic image (Fig 2) showeda large amount of air in the right pararenal space. Itshould be noted, however, that the mere presence ofscanty retroperitoneal air is not always indicative ofperforation: this can be due to over distension by theair introduced.2The radiographic signs of retroperitoneal air or freeintraperitoneal air should be sought on films taken afterERCP if a perforation is suspected. Computed tomo-graphic (CT) scan viewed in the appropriate windowsettings would be a more sensitive method to look forretroperitoneal or intra-abdominal collections (Fig 3).When in doubt, water-soluble contrast examination ofthe upper gastrointestinal tract can be performed. Mostof these collections cannot be drained adequately bypercutaneous procedures under imaging guidance.3Fig 2. Radiographic film of the patient after endoscopicretrograde cholangiopancreatography and biliarystent insertionNote the plastic biliary stent in the common duct (arrows). Alarge amount of air occupies the right pararenal space (*)HKMJ Vol 7 No 3 September 2001      283Abdominal pain after endoscopic interventionFig 3. Axial computed tomographic scan images at the upper abdominal level in another patient with duodenalperforation after endoscopic retrograde cholangiopancreatography(a) at a window width and level setting that is optimal for soft tissue visualisation, the kidneys and the second part of theduodenum can be seen. The retroperitoneal air (arrow) is hypodense to the retroperitoneal fat which, in turn, ishypodense to the soft tissues (viscera and muscles); (b) at a lung window setting, the air collection stands out and canbe differentiated readily from pararenal fat. Paraduodenal collection is absenta. b.Massive subcutaneous emphysema usually indicatesthe necessity of surgical treatment.Many cases of perforation are actually concealedand a negative study cannot exclude the possibilitythat this complication has occurred. In such cases, aconservative management approach is favoured bysome clinicians. Fever and leucocytosis are commonlyseen in these patients and may not indicate treatmentfailure. The lack of leucocytosis in the patient underdiscussion is therefore unusual, especially as no causeof immuno-incompetence can be identified. Thedevelopment of clinical sepsis or peritonism areimportant signs to look for.Summary points• Endoscopic retrograde cholangiopancreatography–related perforations occur in about 1% of patientsand are associated with significant mortality.• Plain radiographic evidence of contrast leakage,retroperitoneal or intra-abdominal air, subcutaneousemphysema, and pneumothorax are important suggest-ive signs of perforation.• Upper gastrointestinal studies with water-solublecontrast and CT scan of the abdomen help in the earlyidentification of surgical candidates and also withmonitoring of medical treatment.• Some cases of perforation can be managed success-fully without resorting to surgery.References1. Stapfer M, Selby RR, Stain SC, et al. Management of duodenalperforation after endoscopic retrograde cholangiopancreato-graphy and sphincterotomy. Ann Surg 2000;232:191-8.2. Dunham F, Bourgeois N, Gelin M, et al. Retroperitonealperforations following endoscopic sphincterotomy; clinicalcourse and management. Endoscopy 1982;14:92-6.3. Genzlinger JL, McPhee MS, Fisher JK, Jacob KM, HelzbergJH. Significance of retroperitoneal air after endoscopicretrograde cholangiopancreatography with sphincterotomy.Am J Gastroenterol 1999;94:1267-70.

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