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A retroperitoneal abscess causing hydronephrosis: An unusual sequela of ERCP
European Journal of Internal Medicine 16 (2005) 219 www.elsevier.com/locate/ejim
Letter to the editor
A retroperitoneal abscess causing hydronephrosis: An unusual sequela of ERCP E.R. Goet, F.G.H. van der KleijT, W.P. Haanstra Department of Internal Medicine, Scheper Hospital Emmen, Boermarkeweg 60, 7824 AA Emmen, The Netherlands Received 3 June 2004; received in revised form 8 November 2004; accepted 28 January 2005
A 62-year-old female presented with chest pain radiating to the upper abdomen. Physical examination and an ECG showed no abnormalities. Laboratory investigation revealed a normal blood count, amylase 6 U/L, AF 87 U/L, SGOT 397 U/L, SGPT 377 U/ L, LD 1451 U/L, gGT 370 U/L, LD 1451 U/L, bilirubin 9 Amol/L, creatinine 56 Amol/L, and a CRP of 18 mg/L. An ultrasound of the abdomen showed an enlarged gallbladder and distended intra- and extrahepatic bile ducts without bile stones. As choledocholithiasis was suspected, an ERCP was performed. A distended bile duct without stones was found. A papillotomy was performed. After 2 days, the patient developed abdominal pain without signs of pancreatitis. A plain abdominal X-ray did not show signs of perforation. An abrupt rise in temperature prompted a computed tomogram (CT). A psoas abscess on the right side and a dilated pyelumcalyces system and proximal ureter were seen. The abscess was thought to have been caused by retroperitoneal perforation as a complication of the ERCP. A percutaneous CT-guided drain was placed in the abscess. The patient was treated with antibiotics guided by positive cultures. Consecutive CT scans showed progressive hydronephrosis. A
T Corresponding author. Tel.: +31 591 691360; fax: +31 591 691361. E-mail address: [email protected] (F.G.H. van der Kleij). 0953-6205/$ - see front matter D 2005 Elsevier B.V. All rights reserved. doi:10.1016/j.ejim.2005.01.003
second drain was inserted and a double J ureteral stent was placed. After 6 weeks, the drains could be removed. A follow-up CT demonstrated complete resolution of the abscess. Retroperitoneal perforation is a well-known complication of ERCP with papillotomy [1]. Risk factors are pre-cut papillotomy, large papillotomy, small-caliber bile ducts, papillary stenosis and, as in this case, peripapillary diverticulum [2]. We describe a patient with retroperitoneal perforation complicated by abscess formation and hydronephrosis. Although rare, clinicians should be aware of this complication.
References [1] Huibregtse K. Complications of endoscopic sphincterotomy and their prevention. N Eng J Med 1996;335:961 – 3. [2] Boender J, Nix GA, de Ridder MA, et al. Endoscopic papillotomy for common bile duct stones: factors influencing the complication rate. Endoscopy 1994;26:209 – 16.
Letter to the editor
A retroperitoneal abscess causing hydronephrosis: An unusual sequela of ERCP E.R. Goet, F.G.H. van der KleijT, W.P. Haanstra Department of Internal Medicine, Scheper Hospital Emmen, Boermarkeweg 60, 7824 AA Emmen, The Netherlands Received 3 June 2004; received in revised form 8 November 2004; accepted 28 January 2005
A 62-year-old female presented with chest pain radiating to the upper abdomen. Physical examination and an ECG showed no abnormalities. Laboratory investigation revealed a normal blood count, amylase 6 U/L, AF 87 U/L, SGOT 397 U/L, SGPT 377 U/ L, LD 1451 U/L, gGT 370 U/L, LD 1451 U/L, bilirubin 9 Amol/L, creatinine 56 Amol/L, and a CRP of 18 mg/L. An ultrasound of the abdomen showed an enlarged gallbladder and distended intra- and extrahepatic bile ducts without bile stones. As choledocholithiasis was suspected, an ERCP was performed. A distended bile duct without stones was found. A papillotomy was performed. After 2 days, the patient developed abdominal pain without signs of pancreatitis. A plain abdominal X-ray did not show signs of perforation. An abrupt rise in temperature prompted a computed tomogram (CT). A psoas abscess on the right side and a dilated pyelumcalyces system and proximal ureter were seen. The abscess was thought to have been caused by retroperitoneal perforation as a complication of the ERCP. A percutaneous CT-guided drain was placed in the abscess. The patient was treated with antibiotics guided by positive cultures. Consecutive CT scans showed progressive hydronephrosis. A
T Corresponding author. Tel.: +31 591 691360; fax: +31 591 691361. E-mail address: [email protected] (F.G.H. van der Kleij). 0953-6205/$ - see front matter D 2005 Elsevier B.V. All rights reserved. doi:10.1016/j.ejim.2005.01.003
second drain was inserted and a double J ureteral stent was placed. After 6 weeks, the drains could be removed. A follow-up CT demonstrated complete resolution of the abscess. Retroperitoneal perforation is a well-known complication of ERCP with papillotomy [1]. Risk factors are pre-cut papillotomy, large papillotomy, small-caliber bile ducts, papillary stenosis and, as in this case, peripapillary diverticulum [2]. We describe a patient with retroperitoneal perforation complicated by abscess formation and hydronephrosis. Although rare, clinicians should be aware of this complication.
References [1] Huibregtse K. Complications of endoscopic sphincterotomy and their prevention. N Eng J Med 1996;335:961 – 3. [2] Boender J, Nix GA, de Ridder MA, et al. Endoscopic papillotomy for common bile duct stones: factors influencing the complication rate. Endoscopy 1994;26:209 – 16.