Case Presentation Post ERCP Perforation From uptodate
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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