PICTURES IN DIGESTIVE PATHOLOGY

 

Small bowel obstruction after ERCP

Obstrucción intestinal completa tras CPRE

 

 

M.^a Antonia Montenegro¹, José Ignacio Blanco², Miguel Toledano³, Javier Sánchez³, Juan Carlos Martín³ and Manuel Pérez-Miranda⁴

¹Department of General Surgery A. Hospital Clínico Universitario. Valladolid, Spain.
²Department of General Surgery. Hospital Universitario Río Hortega. Valladolid, Spain.
³Department of General Surgery. Hospital Medina del Campo. Valladolid, Spain.
⁴Department of Digestive Diseases. Hospital Universitario Río Hortega. Valladolid, Spain

 

 

Endoscopic retrograde cholangiopancreatography (ERCP) with endoscopic sphincterotomy is the treatment of choice for common bile duct (CBD) stones. The complication rate is 5-10% with a mortality rate between 0.5-1.0%.

Post-ERCP complications are usually apparent within three days of the procedure, and rarely present after the 12^th day. Pancreatitis and bleeding are the most common complication. Gallstone ileus after ERCP with CBD removal is exceedingly rare.

 

Case report

A 66 years old male was admitted for cholangitis with obstructive jaundice. Transabdominal US showed cholelithiasis with a 20 mm CBD compatible with choledocholithiasis. He had a history of bilateral inguinal hernia repair, appendectomy and pyloroplasty.

At ERCP a prior small sphincterotomy was enlarged, the papilla was balloon dilated, and all 12 stones found (largest diameter, 25 mm) were removed from the CBD.

After ERCP the patient had bilious vomiting with dilated small bowel loops on abdominal X ray and aerobilia (Figs. 1 and 2). Abdominal CT on day 10 showed a dilated stomach and jejunal loops, with a stone lodged inside the lumen at the terminal ileum (Fig. 3). Emergent laparoscopic surgery was undertaken, where adhesions were found in the left inguinal area, with dilated and torqued small bowel loops. The adhesions were cut, freeing the bowel loop, and cholecystectomy was carried out.

Discussion

Prolonged ERCP with insufflation estimated at over 6 liters of room air in the setting of prior adhesions, triggered in this case small bowel obstruction. This unusual complication has not been reported before. Use of carbon dioxide instead of room air, as it is done in laparoscopy, may prevent this complication in the future.

 

References

1. Pittman MA, Health D, McNair A. Gallstone ileus following endoscopic retrograde colangiopancreatography and endoscopic sphincterotomy. Dig Dis Sci 2007;52:513-5.         [ Links ]

2. Andrabi SIH, Ahmad J, Ahmed M, Yousaf M. Gallstone ileus and bowel perforation: a rare complication of therapeutic ERCP. J Pak Med Assoc 2007;57:375-7.         [ Links ]

3. Goyal A, Srivastava A. Gallstone ileus following endoscopic retrograde cholangiopancreatography and sphincterotomy: a case report. Journal of Medical Case Reports 2008;2:342.         [ Links ]

4. Dellon ES, Velayudham A, Clarke BW, Isaacs KL, Gangorosa LM, Galanko JA, et al. A randomized, controlled, double-blind trial of air insufflation versus carbon dioxide insufflation during ERCP. Gastrointest Endosc 2010;72(1):68-77.         [ Links ]