Pneumopericardium, pneumomediastinum, pneumoretroperitoneum and surgical emphysema secondary to a duodenal perforation post-endoscopic retrograde cholangiopancreatography.

To cite: Harvey JP. BMJ Case Rep Published online: [please include Day Month Year] doi:10.1136/bcr-2015209920 DESCRIPTION A 46-year-old woman presented with severe upper abdominal pain and vomiting 12 h post-endoscopic retrograde cholangiopancreatography (ERCP) and sphincterotomy for choledocholithiasis. The patient also described a sensation of ‘crackling in the neck’ on head rotation. On examination, the patient was stable and afebrile, and had pain in the right hypochondriac region. She had subcutaneous crepitations in the right side of the neck and chest. Blood results showed white cell count 15.5×10/L, C reactive protein 13.7mg/L, amylase 55 IU/L, alanine transaminase 46 IU/L and alkaline phosphatase 300 IU/L; all other blood tests were normal. An erect chest radiograph demonstrated a pneumopericardium, pneumomediastinum and surgical emphysema in the root of the neck (figure 1). An abdominal radiograph showed a large amount of retroperitoneal free air in the upper abdomen and surrounding the kidney—suggesting a duodenal perforation (figure 2). These findings were not present on the preprocedure film (figure 3). The ERCP, performed by an experienced endoscopist, had been without apparent difficulty. During the procedure, a stone was identified as obstructing the distal common bile duct (figure 4). A sphincterotomy was performed and a biliary stent placed (figure 5). The patient was managed conservatively with a nasogastric tube, intravenous fluids and antibiotics. She made a full recovery and was discharged 4 days later. A repeat chest radiograph on discharge showed reabsorption of the free air (figure 6).