SESSION TITLE: Pleural Cases
SESSION TYPE: Affiliate Case Report Slide
PRESENTED ON: Monday, October 28, 2013 at 04:15 PM - 05:15 PM
INTRODUCTION: Endoscopic retrograde cholangiopancreatography (ERCP) is an integral part of gastroenterology practice with a complication rate of 4-10% that largely affects the gastrointestinal tract (GIT).1 However, there are rare occurrences of complications outside of the GIT, and we present a patient who developed bilateral pneumothoraces as a result of ERCP.
CASE PRESENTATION: We admitted a 57 year old woman with a past medical history of metastatic cholangiocarcinoma for right upper quadrant pain and nausea. CT abdomen revealed biliary obstruction, and she underwent ERCP with papillotomy and stent placement. Following ERCP she was tachypneic with low pulse oximetry readings despite supplemental oxygen. She denied any fever or chills, increasing abdominal pain, nausea, vomiting, or chest pain. On physical examination she had extensive neck and facial edema to the level of the periorbital space on the right side, diffuse subcutaneous crepitus of the chest wall bilaterally, and no auscultatory breathe sounds on the left side. Chest X-ray showed a large left pneumothorax, a small right apical pneumothorax, and extensive mediastinal air tracking up to the neck and soft tissues of the chest with extension into the retroperitoneal area. We inserted a chest tube on the left and managed the right conservatively. We admitted the patient to the intensive care unit, and subsequent CT chest and abdomen showed resolution of the pneumothoraces but persistent pneumomediastinum, pneumoretroperitoneum and subcutaneous emphysema. She continued to improve clinically with removal of the chest tube 5 days post procedure.
DISCUSSION: One proposed mechanism for ERCP-related pneumothorax entails air entering the retroperitoneal space after interruption of the duodenal barrier from perforation.2 There is spread to the mediastinum and subcutaneous tissues due to continuum of the fascial planes with mediastinal air entering the pleural space after rupture of the parietal pleura. An alternative hypothesis involves alveolar rupture from increased intra-thoracic pressure in patients with sustained Valsalva maneuvers from poor procedure tolerance.2
CONCLUSIONS: We present our case to illustrate the significance of the unusual complications that can arise from common procedures. In the case of ERCP-related pneumothorax, which is wrought with high morbidity and mortality, timely diagnosis is paramount for optimal management. We advocate for a multi-system approach in the evaluation of patients following any procedure in order to avoid overlooking potentially life-threatening complications.
Reference #1: Fujii L, Lau A, Fleischer DE, Harrison ME. Successful Nonsurgical Treatment of Pneumomediastinum, Pneumothorax, Pneumoperitoneum, Pneumoretroperitoneum, and Subcutaneous Emphysema following ERCP. Gastroenterol Res Pract. 2010; 2010:289135.
Reference #2: Schepers NJ, van Buuren HR. Pneumothorax following ERCP: report of four cases and review of the literature. Dig Dis Sci. 2012 Aug; 57(8):1990-5.
DISCLOSURE: The following authors have nothing to disclose: Denyse Lutchmansingh, Changwan Ryu, Ioana Amzuta
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