Subcutaneous Emphysema, Pneumothorax and Pneumomediastinum Following Endoscopic Sphincterotomy

Abstract

Retroperitoneal perforation during therapeutic endoscopic retrograde cholangiopancreatography (ERCP) is uncommon and is usually manifested by abdominal pain, fever and leukocytosis. We report the case of a patient with post-ERCP subcutaneous emphysema, pneumomediastinum and pneumothorax treated conservatively. A 79-year-old woman with a diagnosis of choledocholitiasis was referred to our institution for an elective outpatient therapeutic ERCP. At the end of the procedure, subcutaneous emphysema was observed, and a thoracic computed tomography revealed a right pneumothorax and pneumomediastinum. Supportive care was instituted and she was discharged asymptomatic after 10 days of hospitalization. Subcutaneous emphysema, pneumothorax and pneumomediastinum are potencial complications of ERCP and sphincterotomy. We review the other cases previously reported and discuss the management.

Subcutaneous emphysema, pneumothorax, pneumomediastinum and pneumoperitoneum after upper gastrointestinal endoscopy

“…Dental care techniques, Valsalva manoeuvre, GI perforation and severe straining may trigger the appearance of subcutaneous emphysema and pneumomediastinum. 8 …”

“…In a freely perforated GI tract, air may flow into the mediastinum through the cavity of the peritoneum via the hiatus oesophagus, and also the Morgagni foramen. It is worth noting that pneumomediastinum in the absence of perforation has been observed after oesophagogastroscopy, 9 colonoscopy or sigmoidoscopy, 10–13 endoscopic sphincterotomy, 8 14 endoscopic polypectomy and air contrast barium enema. 15 16 Reports have also been issued describing pneumothorax for upper GI endoscopy.…”

Periorbital and mediastinal emphysema after upper gastrointestinal endoscopy: Case report of a rare complication

“…[ 3 5 6 7 ] Similarly pneumomediastinum, pneumoperitoneum, and subcutaneous emphysema are known complications following procedures such as upper endoscopy, endoscopic retrograde cholangiopancreatography (ERCP), and colonoscopy, and can occur with or without perforation. [ 8 9 10 ] Pathophysiology of these complications is explained by the anatomical connections between the deep neck fascia, mediastinum, and retroperitoneum, and continuous air insufflations during procedures such as ERCP. When a perforation occurs, free air flows from the duodenum to the retroperitoneal space and then extends to diaphragmatic hiatus causing pneumomediastinum, pneumothorax, and cervical subcutaneous emphysema.…”

“…When a perforation occurs, free air flows from the duodenum to the retroperitoneal space and then extends to diaphragmatic hiatus causing pneumomediastinum, pneumothorax, and cervical subcutaneous emphysema. [ 8 11 ] In those cases without overt perforation, it is postulated that trauma to the duodenal wall by the endoscope causes the insufflated air under pressure to enter the mucosa and track along the perineural and perivascular sheaths to enter the mediastinum. [ 12 ] However, pneumomediastinum with associated orbital emphysema without any cervicofacial trauma is extremely rare.…”

Pneumothorax Following ERCP: Report of Four Cases and Review of the Literature

“…When this is not evident and a patient after ERCP deteriorates clinically, with symptoms and signs suggesting a possible serious complication, abdominal and/or chest CT is indicated [ 34 ]. In many of the reported cases of pneumothorax after ERCP, even extensive radiographic imaging studies failed to show the site of perforation [ 6 , 7 , 12 – 14 , 16 – 18 , 21 ]. Laparotomy may fail to show perforation [ 13 , 15 ] even when this was radiologically shown [ 7 ].…”