Visualisation of the peritoneum during endoscopic retrograde cholangiopancreatography.

An 88-year-old woman was admitted to hospital with severe epigastric pain and ‘coffee grounds’ vomiting. Serum amylase and alanine aminotransferase levels were 1700 U/L (normal range, 25-85 U/L) and 99 U/L (normal range, 10-40 U/L), respectively. Computed tomography scan of the abdomen showed a swollen pancreas with a dilated common bile duct and stones in the gall bladder. The patient deteriorated rapidly and was admitted to the Intensive Care Unit 24 hours later. An urgent ERCP was arranged for her biliary pancreatitis. During ERCP, shortly after the endoscope (TJF140R, Olympus, Tokyo, Japan) was passed across the oesophago-gastric junction, the endoscopist visualised peritoneal content and a loop of small bowel. The procedure was immediately abandoned and the patient was sent for laparotomy. On laparotomy, 2 L of turbid fluid was found. However, there was no apparent perforation site identified despite extensive search. Finally, the same endoscopist performed an on-table endoscopic examination of the stomach using a forward-viewing endoscope (GIFXQ140, Olympus, Tokyo, Japan) and found a 1.5 cm high lesser curve ulcer with a central (2 mm) perforation (Fig). The perforated site of the ulcer was partially sealed with omentum and was apparent only with air insufflation. The ulcer was repaired. Exploration of the common bile duct followed and a T-tube was inserted for drainage of the biliary system. Despite aggressive supportive treatment, the patient died 3 days after surgery due to multiple organ failure.