Case PresentationPost ERCP Perforation

From www.uptodate.com

Dr.Mohammad Amin MirzaGeneral Surgery Resident

Saudi Board in GS(R1)Al-Noor Specialist Hospital

Makkah - 2003

.• B . S• Age : 42 y.o Gender : Female Saudi • Date of admission : 28 – 06 – 1424

AH • Social status : Married , House wife (10 children's ) • Family history : Mother is diabetic

.

• Admitted through OPD with typical history of calculuar cholecystitis .

• H/O itching ; dark color of urine ; normal stool .

• No H/O jaundice • On examination : - Not jaundice . - Chest & CVS – NAD - Abdomen : Soft lax , tender RHC ,

paraumblical bulging (hernia)

.• USG abdomen (19 – 06 – 24 ) : Multiple stones in GB with dilated CBD (9mm) , up to 13 mm it distal end & faint showing seen distally. Small stones ? or sludge , needs further evaluation . No intrahepatic biliary tree dilatation .

• Chemistry : normal on admission .

Indication For ERCP:

- Dilated CBD , containing ? stones - H/O itching ; dark color of urine ERCP done at 29 – 06 – 1424 AH : • Difficult canulation of the ampulla of

Vater ,• Stricture at lower end of CBD • Duadenal diverticulum • Precut sphyncterotomy done• Bile flowing freely

Pt received by Ward nurse at 14:50She noticed that Pt is having face puffiness, gradually increasing abdominal distension, & swelling of the neck with vomiting content of bloody color

• Surgical Emphysema • Vitally stable

Surgical specialist has seen the Pt and informed the consultant on call.

Pt kept NPO , with IVF (3 L\hr) O² 10 L\m

- -USG abdomen : intraperitoneal air, No free fluid intra abdominal, subcut emphysema - CT chest : Bilateral pneumothorax, extensive emphysema retroperitoneal (abdomen & pelvis) Intra abdominal air (large amount); no esophageal injury. - Gastrographin swallow : no esophageal rupture, sever GE reflux, contrast not progressing from antral region on ward for 45 min .

-Consulted Chest surgeon ,, who inserted Rt ICT . and later Lt ICT

Pt Taken to OR for urgent laparotomy at 21:00

• Exploratory laparotomy:• Cholecyctectomy,• Sphyncteroplasty of sphyncter of

Oddi,• T-Tube insertion into CBD,• Feeding jejunostomy tube,• Repair of PUH.

Post operatively Pt was in ICU for close observation for 24 hrs

• Pt is stable • Doing well• Shifted to FSW and remains stable, &

improving.

Patients progress• MRSA – wound infection . (POD 8)• Abdominal wall collection which is

drained and treated by antibiotics according to C/S with dressing BID (POD 27)

• T-Tube is removed (T-Tube Nil , Drain – 200 ml ) and T-Tube cholangiogramm is showing free passage of the die into Duodenum , and no leakage

• US-guided aspiration of retroperitoneal abscess-210cc. C\S Ca.Albicans.

Patient is discharged from the hospital in good

condition to be followed in surgical OPD

First days of Ramadhan 1424

Overview of complications of

E R C P

&

endoscopic biliary sphincterotomy

Classification of complications

.

.

.

Risk factors Overall perforations:• Pt related : -Sphincter of Oddi dysfunction

- A dilated common bile duct.

- Distal CBD Stricture .. Procedure related: - Sphincterotomy - Longer duration of the procedure - Biliary strictuer dilatation

Risk factors

• Risk factors for bowel wall perforation :

- Patients who have stenosis in the upper

gastrointestinal tract or bile ducts - patients who have undergone gastric resection

(Billroth II gastrectomy)

Risk factors

• Risk factors for retroperitoneal perforation:

- precut sphincterotomy and larger sphincterotomies

particularly those that are created outside of the usually

recommended landmarks (11 to 1 o'clock) - small caliber bile duct - the presence of a peripapillary diverticulum - intramural injection of contrast

PREVENTION • The risk of perforation can be minimized when ERCP is

performed by well-trained endoscopists and assistants abiding by the following technique-related principles:

• Proper orientation of the sphincterotome between 11 and 1 o'clock

• Step-by-step incision• Avoiding a "zipper" cut• Sphincterotomy length tailored to the size of

papilla, bile duct, and eventual stone• Judicious use of precut • Appropriate technique in cases of anatomical

variants such as peripapillary diverticula and Billroth II gastrectomy

MANAGEMENT • NPO ,proper hydration , NGT , or naso-duodenal tube ,

& IV antibiotics .• Patients with esophageal and free abdominal gastric,

jejunal, or duodenal perforation usually require surgery: - choledochotomy with stone extraction and T-tube

drainage, - repair of the perforation, - drainage of abscess or phlegmon, - choledochojejunostomy, or pancreatoduodenectomy- nasobiliary tube (during ERCP)

- Percutaneous drainage - TPN for Pt who are expected to remain on bowel rest for at least

one week

Conclusion

Close observation of patients who underwent

ERCP at least 6 hours after procedure is mandatory by

the resident on duty , especially the cases which

had difficulty in the procedure