A 65-year-old female presented with right upper quadrant pain and vomiting for 5 days. Imaging showed CBD stones. During a difficult ERCP involving pre-cut sphincterotomy, the patient developed tension pneumothorax. Exploration found a duodenal tear that was repaired. Tension pneumothorax is a rare but serious complication of ERCP due to retroperitoneal or intraperitoneal air dissection through diaphragmatic pores. Immediate diagnosis and treatment is needed to prevent hemodynamic compromise.

1. Clinical scenario
Ibrahim Masoodi

2. History
• 65/F
• Right UQ pain and vomiting - 5 days.
• O/E conscious, oriented,
• Jaundiced + BP=120/80
• Temp.37 Ox sat= 94% on room air.
• RHQ tenderness,
• no organomegaly,
• no palpable lump /No free fluid
• Systemic examinations - unremarkable.

3. CBC
Value
Hb 13g/dl
TLC 14.0 x 10³,
DLC predominantly neutrophilic
(polymorphs 92%).
Platelets 200x100,00

4. Chemistry
Urea 20MG
Creatinine 1.1mg
Na/K 138/3.9
Bil 21.6 umol/L, direct bilirubin of
9.7 umol/L,
AST 300 umol/L
ALT 317 umol/L
ALP 488 umol/L
Albumin 3.8
Total protein 4.2

5. USG
Prominent CBD-
porta hepatis, intra-
hepatic biliary ductal
dilatation and
cholelithiasis.
Antibiotics and
intravenous fluids.
ERCP

6. ERCP
ERCP-
Duodenal
diverticulum
Just across ,
proximal to the
ampulla

7. Cholangiogram
Difficulty in cannulation .
Precutsphincterotomy
,needle knife
Successful selective CBD
cannulation.
Cholangiogram - dilated
CBD 4 filling defects -CBD
stones

8. ERCP
Sphincterotomy extended with the sphincterotome
 4 stones removed
Balloon occlusion cholangiogram -No filling defect.
Soon after the procedure the patient became tachypneic
and hypoxic.
 The O2 saturation dropped to 66%, and she became
hypotensive-80/60mm

9. Cause of hypotension?

10. Examination:
 Chest examination :
Deviation of trachea and mediastinum to the
left
Hyperresonant percussion note
Absent breath sound on the right hemithorax
There was abdominal distension with diffuse
mild tenderness.
Chest x-ray on table

11. X-ray chest
confirmed
right-sided
pneumothorax,
and free air
under the right
hemidiaphragm

12. On ERCP table
A wide-pored cannula was placed in the 2nd
inter-costal space anteriorly
Partially relieved her distress.
Marginal improvement in her oxygen
saturation.
Patient shifted to intensive care

13. ICU Course
 A chest tube was placed in the right side by the
thoracic surgeon.
She was intubated and placed on mechanical
ventilator.
The patient’s oxygen saturation improved
Hypotensive requiring inotropic support and broad
spectrum antibiotics.

14. Exploratory Laparotomy
Revealed a 3cm tear over the
lower anteriolateral aspect of
the second part of the
duodenum
No bile duct perforation was
visualized.
 The duodenal laceration was
sutured in 2 layers and
reinforced by an omental patch.
 Cholecystectomy .

15. Post operative course
Chest tube removed - 5 days.
Complications-
1.Recurrent pneumonia
2. intra-abdominal fluid collection around the
retroperitoneal part of the duodenum
Drained percutaneously - CT guidance with placement
of a drainage catheter.
Discharged in a stable condition after 21days.
Follow up> 2yrs: No evidence of duodenal stenosis

16. CBD stones
10% of patients with symptomatic gallstones -common
bile duct stones
Laparotomy with CBD exploration
by T-tube, C-tube insertion, or primary closure
Preoperative ERCP with or without endoscopic biliary
sphincterotomy,
 Laparoscopic CBD exploration
(transcystic or transcholedochal),
One-stage ERCP and laparoscopic cholecystectomy

17. Complications of ERCP
Pancreatitis,
Bleeding,
cholangitis and perforation.
Overall, the procedure carries a death rate of 1.0%
to 1.5 %

18. Duodenal diverticula in the
index case
Pathology of duodenal diverticula ?/ second to colon
Asymptomatic in 90% of cases.- GI hemorrhage
Endoscopy, contrast X-rays /intra-operative finding
ERCP Cannulation - difficult /skills.
Higher risk of retained stones in the common bile
duct -complication rate .

19. Why Tension pnuemothorax ?
Pre-cut needle knife sphincterotomy was
made.
 The long duration of ERCP with accompanied
insufflation of air for lumen patency can
predispose to rupture of duodenal
diverticulum
Pneumoperitoneum & tension pneumothorax

20. Classification of CBD perforation
Free bowel perforations, or perforations of bile
duct.
Classified the perforations in relation to mechanism,
anatomical location, and severity of injury- predict
the need for surgery.
 4 types in descending order of severity:
Type I- Lateral or medial wall duodenal perforation
 Type II- Peri-Vaterian injuries
Stapfer et al. Annals of surgery 2000

21. Types of perforations
Type III- distal bile duct injuries related to
wire/basket instrumentation;
Type IV- retroperitoneal air alone.
 Type IV is probably related to the use compressed air
to maintain the patency of the duodenal lumen- in air
diffusion within the layers of duodenal lumen wall or
outside the lumen, as in pneumatosis cystoides
• Stapfer et al. Annals of surgery 2000

22. Post ERCP pneumotorax
Pneumothorax is a serious but rare complication of
ERCP .
It can be a result of both intraperitoneal duodenal
perforation &Retroperitoneal duodenal perforation .
Various clinical courses and presentations of post-
ERCP duodenal perforations depending on the extent
of the perforation.

23. Review
Lee et al. reported tension pneumothorax
with a complicating microperforation
following ERCP
Hui et al. reported a case of tension
pneumothorax complicating ERCP in a patient
with Billroth II gastrectomy
 Macklin etal the phenomenon of extra-
alveolar air leak from high intrapulmonary
airway pressures

24. Mechanism
Air dissects along perivascular sheaths to
the mediastinum -to the neck, subcutaneous
tissues, and extraperitoneal spaces
Unabated airway pressure can force air from
the retroperitoneum into the free peritoneal
cavity with resulting pneumoperitoneum.
Communications between the pleural space
and the peritoneum by pleuroperitoneal
defects

25. Contd.
Diaphragmatic pores or “stomata of von
Recklinghausen” form when the cell margins of
lymphatic endothelial and mesothelial cells lining the
peritoneal surface of the diaphragm come together-
an open channel between the peritoneal cavity and
lymphatic lacunae.
Gases (from a therapeutic or spontaneous
pneumoperitoneum),
 Tissue (endometrium with catamenial pneumothorax
or hemothorax

26. CONTD.
Secretions ,from a subhepatic abscess,
pancreatic pseudocyst, bilothorax &intestinal
content (perforated peptic ulcer) may pass.
 A large bore is not needed for tension
pneumothorax.
It can develop even one or two days later if
intestinal air leakage is continued
 pathways -tension pneumothorax associated
with tension pneumoperitoneum.

27. Management
Early recognition and appropriate management
 Surgical indications : Acute peritoneal irritation
signs with or without sepsis,
 Documentation of large contrast extravasation,
presence of intra- or retroperitoneal fluid
collections
Type 1 perforations were usually managed by
surgery, while surgery is less likely in other types
(Stapfer et al.)

28. Take home message
ERCP related perforations - 1% of patients
Death rate of 16% to 18%
 Periampullary diverticula make cannulation of the
common bile duct more difficult and may predispose
to ERCP-related duodenal perforations.
Tension pneumothorax is a rare life-threatening
complication of ERCP duodenal perforation
Requires immediate recognition and MANAGEMENT