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Bilateral Pneumothoraces as a Complication of Endoscopic Retrograde Cholangiopancreatography
The Journal of Emergency Medicine, Vol. -, No. -, pp. 1–3, 2016 Ó 2016 Elsevier Inc. All rights reserved. 0736-4679/$ - see front matter
http://dx.doi.org/10.1016/j.jemermed.2016.11.023
Visual Diagnosis in Emergency Medicine
BILATERAL PNEUMOTHORACES AS A COMPLICATION OF ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY Douglas E. Rappaport, MD,* Joshua J. Solano, MD,* and Jonathan A. Edlow, MD Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts and Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts Reprint Address: Joshua J. Solano, MD, Department of Emergency Medicine, Beth Israel Deaconess Medical Center, 1 Deaconess Road, West Clinical Center 2, Boston, MA 02215
duodenal perforation during ERCP (1,2). Given the frequency at which ERCP is performed, and the fact that patients are often discharged home several hours after the procedure, complications are often first seen and managed in the emergency department.
INTRODUCTION Endoscopic retrograde cholangiopancreatography (ERCP) is one of the most commonly performed endoscopic procedures by gastroenterologists, with a multitude of indications. While generally well tolerated, complications are not infrequent and can be associated with significant morbidity and mortality. A systematic review published in 2007 that looked at the incidence of post-ERCP complications of nearly 17,000 patients found that the risk of pancreatitis is 3.5%, infection 1.4%, bleeding 1.3%, and perforations 0.6% (1). Several other reports have cited similar incidence of perforation occurring at around 0.6%–1% (2). Despite the low incidence, mortality associated with perforation approaches nearly 10% (1). The most significant risk factor for perforation seems to be sphincterotomy and the most common sites of perforation include the duodenum and biliary system (2,3). Commonly associated complications of duodenal perforation include peritonitis, intraperitoneal and retroperitoneal free air, subcutaneous emphysema, and pneumomediastinum. Additionally, there are case reports in the literature that describe pneumothorax occurring in the setting of
CASE REPORT A 65-year-old male presented to the emergency department complaining of abdominal pain in the setting of an ERCP performed earlier that day for common bile duct stent removal. The patient stated that he experienced some mild nausea after the procedure that was alleviated with oral antiemetics. However, several hours later, he reported severe and progressively worsening abdominal pain and distension. Physical examination was notable for tachycardia, tachypnea, and a distended, rigid abdomen that was diffusely tender to palpation. Computed tomography scan with i.v. contrast of the abdomen/pelvis showed duodenal perforation with free air extending into retroperitoneum (Figure 1A, B), dissecting through fascial planes, mediastinum, and pleural spaces and resulting in bilateral pneumothoraces (Figure 2A). The patient underwent emergent bilateral tube thoracostomy with pigtail catheters and subsequent laparotomy and repair of duodenal injury (Figure 2B). His postoperative course was uncomplicated and the patient fully recovered.
* These authors contributed equally to the study.
RECEIVED: 6 November 2016; ACCEPTED: 13 November 2016 1
2
D. E. Rappaport et al.
Figure 1. (A) Scout radiograph showing evidence of retroperitoneal, pneumothorax (arrows). (B) Computed tomography scan image of a coronal section of torso with retroperitoneal air, and bilateral pneumothoraces (arrows).
DISCUSSION Although pneumothorax is a described phenomenon associated with duodenal perforation in the context of ERCP, it is exceedingly rare and there are no published data on the exact incidence of pneumothorax specifically as a complication. Furthermore, all published data come solely from case reports of approximately 20 patients (2). At present, the authors are unaware of any such reports published in the emergency medicine literature. The pathophysiologic mechanism by which duodenal perforation leads to mediastinal free air and pneumothoraces is not entirely clear. One suggested mechanism involves air directly dissecting from the retroperitoneum
through the abdominal and cervical fascial planes, into the mediastinum, and subsequently gaining access to pleural cavity via rupture of the parietal pleura resulting in pneumothorax (2). A second suggested mechanism suggests that congenital pores in the diaphragm allow retroperitoneal air to leak directly into the pleural space causing pneumothorax (2). With regard to the management of pneumothorax in this context specifically, a majority of cases have been managed conservatively with tube thoracostomy, supplemental oxygen, i.v. antibiotics, and n.p.o. status (2,3). There is debate about whether the presence of a pneumothorax alone is a hard indication for surgical intervention (3). It should be noted that these recommendations are based solely on case reports and there
Figure 2. (A) Portable radiograph showing subcutaneous air as well as pneumothorax and pneumomediastinum (arrows). (B) Portable radiograph showing placement of bilateral pigtail catheters (arrows).
Bilateral Pneumothoraces after ERCP
are no published data directly comparing surgical and nonsurgical management approaches to this complication. Generally, duodenal perforation during ERCP is recognized during the procedure or in its immediate aftermath. Nevertheless, there are a large number of cases in which the complication goes unrecognized and it is up to the emergency physician to evaluate, diagnose, and manage this complication appropriately.
3
REFERENCES 1. Andriulli A, Loperfio S, Napolitano G, et al. Incidence rates of postERCP complications: a systematic survey of prospective studies. Am J Gastroenterol 2007;102:1781–8. 2. Schepers N, Van Buuren H. Pneumothorax following ERCP: four cases and review of the literature. Digest Dis Sci 2012;57:1990–5. 3. Kwon C, Song S, Hahm KB, et al. Unusual complications related to endoscopic retrograde cholangiopancreatography and its endoscopic treatment. Clin Endosc 2013;43:251–9.
http://dx.doi.org/10.1016/j.jemermed.2016.11.023
Visual Diagnosis in Emergency Medicine
BILATERAL PNEUMOTHORACES AS A COMPLICATION OF ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY Douglas E. Rappaport, MD,* Joshua J. Solano, MD,* and Jonathan A. Edlow, MD Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts and Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts Reprint Address: Joshua J. Solano, MD, Department of Emergency Medicine, Beth Israel Deaconess Medical Center, 1 Deaconess Road, West Clinical Center 2, Boston, MA 02215
duodenal perforation during ERCP (1,2). Given the frequency at which ERCP is performed, and the fact that patients are often discharged home several hours after the procedure, complications are often first seen and managed in the emergency department.
INTRODUCTION Endoscopic retrograde cholangiopancreatography (ERCP) is one of the most commonly performed endoscopic procedures by gastroenterologists, with a multitude of indications. While generally well tolerated, complications are not infrequent and can be associated with significant morbidity and mortality. A systematic review published in 2007 that looked at the incidence of post-ERCP complications of nearly 17,000 patients found that the risk of pancreatitis is 3.5%, infection 1.4%, bleeding 1.3%, and perforations 0.6% (1). Several other reports have cited similar incidence of perforation occurring at around 0.6%–1% (2). Despite the low incidence, mortality associated with perforation approaches nearly 10% (1). The most significant risk factor for perforation seems to be sphincterotomy and the most common sites of perforation include the duodenum and biliary system (2,3). Commonly associated complications of duodenal perforation include peritonitis, intraperitoneal and retroperitoneal free air, subcutaneous emphysema, and pneumomediastinum. Additionally, there are case reports in the literature that describe pneumothorax occurring in the setting of
CASE REPORT A 65-year-old male presented to the emergency department complaining of abdominal pain in the setting of an ERCP performed earlier that day for common bile duct stent removal. The patient stated that he experienced some mild nausea after the procedure that was alleviated with oral antiemetics. However, several hours later, he reported severe and progressively worsening abdominal pain and distension. Physical examination was notable for tachycardia, tachypnea, and a distended, rigid abdomen that was diffusely tender to palpation. Computed tomography scan with i.v. contrast of the abdomen/pelvis showed duodenal perforation with free air extending into retroperitoneum (Figure 1A, B), dissecting through fascial planes, mediastinum, and pleural spaces and resulting in bilateral pneumothoraces (Figure 2A). The patient underwent emergent bilateral tube thoracostomy with pigtail catheters and subsequent laparotomy and repair of duodenal injury (Figure 2B). His postoperative course was uncomplicated and the patient fully recovered.
* These authors contributed equally to the study.
RECEIVED: 6 November 2016; ACCEPTED: 13 November 2016 1
2
D. E. Rappaport et al.
Figure 1. (A) Scout radiograph showing evidence of retroperitoneal, pneumothorax (arrows). (B) Computed tomography scan image of a coronal section of torso with retroperitoneal air, and bilateral pneumothoraces (arrows).
DISCUSSION Although pneumothorax is a described phenomenon associated with duodenal perforation in the context of ERCP, it is exceedingly rare and there are no published data on the exact incidence of pneumothorax specifically as a complication. Furthermore, all published data come solely from case reports of approximately 20 patients (2). At present, the authors are unaware of any such reports published in the emergency medicine literature. The pathophysiologic mechanism by which duodenal perforation leads to mediastinal free air and pneumothoraces is not entirely clear. One suggested mechanism involves air directly dissecting from the retroperitoneum
through the abdominal and cervical fascial planes, into the mediastinum, and subsequently gaining access to pleural cavity via rupture of the parietal pleura resulting in pneumothorax (2). A second suggested mechanism suggests that congenital pores in the diaphragm allow retroperitoneal air to leak directly into the pleural space causing pneumothorax (2). With regard to the management of pneumothorax in this context specifically, a majority of cases have been managed conservatively with tube thoracostomy, supplemental oxygen, i.v. antibiotics, and n.p.o. status (2,3). There is debate about whether the presence of a pneumothorax alone is a hard indication for surgical intervention (3). It should be noted that these recommendations are based solely on case reports and there
Figure 2. (A) Portable radiograph showing subcutaneous air as well as pneumothorax and pneumomediastinum (arrows). (B) Portable radiograph showing placement of bilateral pigtail catheters (arrows).
Bilateral Pneumothoraces after ERCP
are no published data directly comparing surgical and nonsurgical management approaches to this complication. Generally, duodenal perforation during ERCP is recognized during the procedure or in its immediate aftermath. Nevertheless, there are a large number of cases in which the complication goes unrecognized and it is up to the emergency physician to evaluate, diagnose, and manage this complication appropriately.
3
REFERENCES 1. Andriulli A, Loperfio S, Napolitano G, et al. Incidence rates of postERCP complications: a systematic survey of prospective studies. Am J Gastroenterol 2007;102:1781–8. 2. Schepers N, Van Buuren H. Pneumothorax following ERCP: four cases and review of the literature. Digest Dis Sci 2012;57:1990–5. 3. Kwon C, Song S, Hahm KB, et al. Unusual complications related to endoscopic retrograde cholangiopancreatography and its endoscopic treatment. Clin Endosc 2013;43:251–9.