Pneumoperitoneum after Endoscopic Duodenal Stent Insertion in a Patient with Percutaneous Transhepatic Biliary Drainage and Biliary Stent: A Case Report

Abstract

Early removal of a percutaneous transhepatic biliary drainage (PTBD) tube commonly causes pneumoperitoneum. However, we encountered a patient who developed pneumoperitoneum even with an indwelling PTBD tube. An 84-year-old man was admitted with type III combined duodenal and biliary obstruction secondary to metastatic bladder cancer. A biliary stent was placed using a percutaneous approach, and a duodenal stent was placed endoscopically. A large amount of subphrenic free air was detected after the procedures. Laboratory tests indicated intestinal perforation; however, peritoneal signs were absent. The patient was treated conservatively using an indwelling Levin tube. Seven days later, the massive amount of subphrenic free air disappeared. Follow-up tubography revealed unrestricted bile flow into the small intestine, and the PTBD tube was removed. Prolonged endoscopic procedures in patients with a PTBD tract communicating with the gastrointestinal tract can precipitate pneumoperitoneum. Clinicians should be careful to avoid misdiagnosing this condition as intestinal perforation.

The characteristics of residual pneumoperitoneum after laparoscopic colorectal surgery

“…Nonsurgical pneumoperitoneum can occur due to thoracic, abdominal, obstetric and gynecologic, and iatrogenic causes 3 . Various cases of iatrogenic pneumoperitoneum have been reported, and residual pneumoperitoneum after surgery occurs due to iatrogenic causes 4–10 . Nonsurgical pneumoperitoneum should be managed with conservative treatment and careful monitoring when the patient does not have clinical signs or symptoms of peritonitis 3,11 .…”

“…3 Various cases of iatrogenic pneumoperitoneum have been reported, and residual pneumoperitoneum after surgery occurs due to iatrogenic causes. [4][5][6][7][8][9][10] Nonsurgical pneumoperitoneum should be managed with conservative treatment and careful monitoring when the patient does not have clinical signs or symptoms of peritonitis. 3,11 Nevertheless, it can be difficult to distinguish between residual pneumoperitoneum and free air caused by anastomotic failure, especially after gastrointestinal surgery, and residual pneumoperitoneum can lead to invasive procedures (eg, exploratory laparotomy) if the patient experiences symptoms.…”