Pneumomediastinum and subcutaneous emphysema after perforation of the duodenum during gastroscopy

Subcutaneous Emphysema, Pneumothorax and Pneumomediastinum Following Endoscopic Sphincterotomy

Retroperitoneal perforation during therapeutic endoscopic retrograde cholangiopancreatography (ERCP) is uncommon and is usually manifested by abdominal pain, fever and leukocytosis. We report the case of a patient with post-ERCP subcutaneous emphysema, pneumomediastinum and pneumothorax treated conservatively. A 79-year-old woman with a diagnosis of choledocholitiasis was referred to our institution for an elective outpatient therapeutic ERCP. At the end of the procedure, subcutaneous emphysema was observed, and a thoracic computed tomography revealed a right pneumothorax and pneumomediastinum. Supportive care was instituted and she was discharged asymptomatic after 10 days of hospitalization. Subcutaneous emphysema, pneumothorax and pneumomediastinum are potencial complications of ERCP and sphincterotomy. We review the other cases previously reported and discuss the management.

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

Background

The 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 presentation

We 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.

Conclusion

There 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.

Pathophysiology, recognition and management of pneumoretroperitoneum

The medical records of 15 patients found to have pneumoretroperitoneum in a 10-year period were reviewed. The cause of retroperitoneal emphysema was infection in six patients, trauma in five and iatrogenic in four. Emphysema was confined to the retroperitoneum in 11 patients, and extended to the mediastinum in four and to the soft tissue of the neck in three. Failure to diagnose pneumoretroperitoneum resulted in delayed intervention in two patients. One patient with pneumoretroperitoneum and pneumoperitoneum secondary to a lung lesion underwent unnecessary laparotomy. Outcome was favourable in these three patients. The presence of air in the retroperitoneum is not dangerous but its early recognition and detection of the source are important as septic conditions may be involved.

Retroperitoneal-pericardial fistula caused by a perinephric abscess

A case of a perinephric abscess complicated by a fistulous tract leading to the pericardium is presented. We report herein on the conventional radiological findings.

Complications of fiberoptic endoscopy

This review summarizes the complications of fiberoptic peroral endoscopy, endoscopic retrograde cholangiopancreatography and colonoscopy gleaned from reports of extensive endoscopic surveys. Unique individual experiences are also included. Means whereby complications can be prevented or remedied are noted.