MDCT Findings in Iatrogenic Duodenal Perforation

Abstract

Iatrogenic duodenal perforation following ERCP/ endoscopic sphincterotomy is a rare complication. Prompt diagnosis and management will help reduce the morbidity and mortality associated with this condition. CT is the imaging modality of choice in patients suspected with duodenal perforation. We present the CT findings in two patients who had iatrogenic duodenal injury. KEYWORDS: Iatrogenic duodenal perforation, perinephric collection, endoscopic retrograde cholangio-pancreatico-graphy (ERCP), endoscopic sphincterotomy, multi detector computed tomography (MDCT) Case 1:A 45 year old woman had presented with jaundice and upper abdominal pain. Ultrasonography showed cholelithiasis and a dilated CBD. Patient had a duodenal injury while undergoing an ERCP procedure. An erect chest radiograph (CXR) shows dilated bowel loops with no evidence of pneumo-peritoneum (fig 1). Patient was managed conservatively. As the patient developed fever, a CT scan was done which revealed a heterogeneous retroperitoneal collection with multiple air pockets within it. The collection is located in a right perinephric location and is seen to tract along the right psoas muscle (fig 2). Case 2:A 65 year old woman who had undergone cholecystectomy earlier presented with history of jaundice. An MRCP done revealed a mid CBD stricture with dilated intrahepatic biliary radicals (IHBR's). An ERCP was planned to stent the CBD. There was a duodenal injury while negotiating the guidewire. The procedure was abandoned and an immediate chest radiograph done did not reveal air under the diaphragm (fig 1). A CT done shows a right perinephric retroperitoneal collection with few air pockets within it (fig 3).Imaging Protocol: CT imaging was done on a 128 slice Philips ingenuity CT scanner. CT scan of the abdomen and pelvis was done for both patients with administration of oral contrast for the first patient. Dual phase scanning was done with arterial phase at a delay of 30sec and the portal venous phase at a delay of 75 sec from the time of injection. 120 ml of non iodinated contrast media was injected at a flow rate of 3ml/sec through a power injector. CT sections were taken at a slice thickness of 2mm and reconstructed at an interval of 1mm. DISCUSSION:

Management of horizontal duodenal perforation: a report of three cases and review of literature

“…Chest and erect abdominal radiography and ultrasonography are not of diagnostic value, and the modality of choice is CT scan with both oral and intravenous contrast media [ 2 , 3 ]. Factors like anatomical location of the injury, type and extent of injury, associated injuries to other structures and organs, and time of surgery determine the type of surgical options and their outcome [ 8 ].…”

“…It extends from the fourth lumbar vertebra to the level of the aorta. Since this part is adjacent to the spine, it is often affected by trauma [ 2 ]. The clinical examination result is initially negative and may appear only when the duodenal contents enter the peritoneal cavity.…”