Life-Threatening Duodenal Perforation Following Endoscopic Retrograde Cholangiopancreatography in an Elderly Patient: A Case Report

TL;DR

An elderly man experienced a life-threatening duodenal perforation after an ERCP procedure, highlighting the rare but severe risks of this medical intervention.

Contribution

This case report emphasizes the critical importance of early diagnosis and tailored management of ERCP-related perforations in high-risk patients.

Findings

ERCP led to duodenal perforation with severe complications including emphysema and pneumothoraces.

CT imaging confirmed retroperitoneal contrast extravasation and intraperitoneal air.

Despite emergency repair and intensive care, the patient succumbed to septic shock and multi-organ failure.

Abstract

Endoscopic retrograde cholangiopancreatography (ERCP) is a valuable diagnostic and therapeutic procedure for pancreaticobiliary disorders, but may rarely result in severe complications such as duodenal perforation. A 77-year-old man with hypertension, diabetes, dyslipidemia, and benign prostatic hyperplasia presented with painless obstructive jaundice for a duration of four weeks. Laboratory tests showed a cholestatic pattern and elevated carbohydrate antigen 19-9. Magnetic resonance cholangiopancreatography (MRCP) demonstrated marked dilation of the common bile duct with abrupt distal tapering, mild pancreatic duct dilation, and a periampullary diverticulum, suggesting a periampullary neoplastic lesion or fibrotic stenosis. An ERCP was performed for diagnostic clarification and potential therapeutic decompression. Difficult cannulation required a precut sphincterotomy, after which a duodenal perforation was suspected. Post-procedure, the patient developed extensive subcutaneous, retroperitoneal, and mediastinal emphysema, pneumopericardium, and bilateral pneumothoraces. A CT confirmed free intraperitoneal air and contrast extravasation in the retroperitoneal space anterior to the left renal fascia, consistent with a perforation of the third portion of the duodenum. Emergency laparotomy identified and repaired the defect with a Graham patch. Despite intensive care with broad-spectrum antimicrobials and vasopressors, the patient developed septic shock and multi-organ failure and died nine days later. This case underscores the catastrophic potential of ERCP-related duodenal perforation and the importance of early CT diagnosis and individualized intervention in high-risk patients.

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