Subcutaneous emphysema, pneumomediastinum and pneumoperitoneum after unsuccessful ERCP: a case report

Abstract

BackgroundThe presence of subcutaneous emphysema, pneumomediastinum and pneumoperitoneum simultaneously is a rare complication of upper gastrointestinal endoscopy that usually indicates free perforation to the peritoneal cavity or the retroperitoneal space.Case presentationWe report an unusual case of a self-limited subcutaneous emphysema, pneumomediastinum and pneumoperitoneum following an unsuccessful ERCP for removal of a common bile duct stone.ConclusionThere was no radiological evidence of peritoneal or retroperitoneal perforation. This complication is distinct from pneumomediastinum and pneumoperitoneum due to perforation, and must be recognized, because it is benign and needs no surgical or radiological intervention.

Pneumomediastinum, pneumoperitoneum, and pneumoretroperitoneum secondary to afferent loop perforation after upper endoscopy in patient with Billroth II gastrectomy

“…Even if all above negative image studies, up to 10% cases of perforation could not be detected. [8] According to 2014 European Society of Gastrointestinal Endoscopy (ESGE) guideline for managements of iatrogenic endoscopic perforations, [9] treating endoscopy related duodenal perforation depends on recognition time (instant or delayed > 24 hour), whether pos-sible endoscopic closure after immediate recognition, and any extravasation on CT finding. But the evidences are almost coming from ERCP related duodenal perforation.…”

The Management of Perforation after Endoscopic retrograde cholangiopancreatography (ERCP).

“…[9][10][11] Recently, it has been reported that most retroperitoneal perforations could be treated with conservative medical therapy; some authors have concluded that guidewire perforations are generally benign and do not require surgery. [12][13][14] Certain patients are likely to improve under conservative management, which includes hospitalization, intestinal rest, and administration of intravenous fluids and antibiotics to limit peritonitis and allow perforation to seal. However, patients should undergo careful observation with frequent and repeated abdominal exams for early diagnosis of peritonitis.…”

“…[7,[9][10][11][12] Wu et al concluded that periampullary perforations should be treated aggressively with broad spectrum antibiotics, fasting, and aggressive endoscopic bile diversion (biliary stent or nasobiliary tube) from site of perforation. [9] The authors went on to say that surgery is required if retroperitoneal fluid is seen on abdominal CT or if clinical picture worsens in 24 hours.…”

Simultaneous Pneumatosis Cystoides Intestinalis and Pneumomediastinum in a Patient with Systemic Sclerosis

“…Pneumomediastinum is a rare complication of GI endoscopy, and it usually indicates perforation leading into the peritoneal cavity or the retroperitoneal space that results from trauma to the GI mucosa 8 . Air enters the bowel wall by the mucosal wound and ascends through the retroperitoneum, tracking upward to reach the mediastinum.…”

“…Air enters the bowel wall by the mucosal wound and ascends through the retroperitoneum, tracking upward to reach the mediastinum. This can occur without any overt evidence of perforation 8 . This ascending route from the intestine is more reasonable in our patient, since her chief complaint was abdominal distension, and abdominal radiographs showed marked small bowel dilation (similar to that after endoscopic insufflation).…”