ERCP complications can occur in the short term (within three days) and long term (> 3 days). Short-term complications include bleeding, infection, perforation, and cardiopulmonary events. A prospective series of ERCP reported a short-term complication rate of approximately 5 to 10%. [1] Infections due to indwelling stents and inflammatory changes due to ductal manipulation are responsible for most long-term complications. The incidence of ERCP complications ranges from 5% to 40%. The procedure’s complexity, underlying diagnosis, and comorbidities influence the occurrence of complications. The most common complication is pancreatitis after ERCP. Others are cholangitis, duodenal haemorrhage, stent migration, and duodenal perforation.[2]

Gastroduodenal perforation-related ERCP procedure is a relatively scarce but life-threatening condition.[3] The mortality rate of gastrointestinal perforation reported in the literature is around 8 to 25%.[4][5][6] A perforation that can be contained by surrounding organs results in a contained perforation. In contrast, a free perforation occurs when gastric contents spill freely into the peritoneal cavity, resulting in generalized peritonitis.[7] The most common etiology is peptic ulcer disease (PUD).[8] Normally, patients with perforation experience intense pain in the upper abdomen. [9] Although in elderly or immunocompromised patients, clinical signs can be subtle, and diagnosis may be delayed. Imaging plays an important role in diagnosis and early resuscitation. A timely assessment of risk and sound therapeutic management is crucial in reducing morbidity and mortality.[10]

Case Report

A 73-year-old man presented to our hospital with a complaint of progressive abdominal pain, accompanied by nausea and vomiting. He had a history of obstructive jaundice one year prior and was treated with a common bile duct (CBD) stent via endoscopic retrograde cholangiopancreatography (ERCP) at our hospital. The patient’s vital signs were normal except for a slight fever at 37,8 degrees Celsius. Upon examination, the abdomen was found to have decreased bowel sounds, with generalized guarding. A digital rectal examination was performed and also revealed generalized tenderness. Laboratory results revealed leukocytosis at 21,900 cells/µL and neutrophilia at 91.6%. An abdominal series was performed, but there was no sign of subdiaphragmatic air or other signs of perforation. 

Emergent exploratory laparotomy was performed. Upon entering the peritoneum, there was approximately 300 mL of yellowish fluid. A sample was taken for cultures. Abdominal washing was then performed. After a brief exploration, we found a small perforation of the duodenum. Protruding out of the perforation was the biliary stent, which we extracted. The duodenal perforation was sutured, then overlayed with an omental patch. We then performed a cholecysto-jejunostomy anastomosis. The stomach was opened and pyloric exclusion was performed, followed by gastrojejunostomy and jejuno-jejunostomy. A jejunal feeding catheter was placed, and a concomitant appendectomy was performed.    

Seven days after the laparotomy, the patient's condition was good with reduced pain,no vomit, normal defecation, no complication, and outward from the hospital with jejenal feeding tube taken home.

Figure 1: a. Showed migration of stent post ERCP in the duodenum (via endoscopy), b. Abdominal X-Ray, erect position, c. Free air appearance on Abdominal X-Ray, supine position, d. Free air appearance on Left Lateral Decubitus Abdominal X-Ray. (Source: Courtesy of Dr. dr. Ida Bagus Budhi SA, Sp.B(K)BD, M.Kes)  

Fig. 2 The migration of stent at duodenum part III

Four million people worldwide are affected by peptic ulcer disease. The incidence rate is 1,5 to 3%.[11] Although the incidence of PUD is decreasing, gastroduodenal perforation due to PUD is still a major problem. Perforation ensues in approximately 5% of people with PUD within their lifetime. The elderly population and excessive nonsteroidal anti-inflammatory drugs (NSAIDs) consumption are possible explanations for the high perforation rate.[12] Studies show that Helicobacter pylori infection is found in 50 to 80% of patients with perforated ulcers.[13] Other studies described that most perforations occur in the morning, attributed to circadian variations in acid secretion.[14]

Post-ERCP duodenal perforation is reported to have an incidence of 0.09 to 1.67%. Predisposing factors include Oddi sphincter dysfunction, advanced age, anatomic abnormalities, and use of contrast media.[15][16] Concerning traumatic perforation, less than 2% of abdominal trauma involves the duodenum, and under 1% of gastrointestinal perforation takes place due to swallowed foreign bodies.[17][18] Other perforation causes include Zollinger-Ellison syndrome, duodenal diverticula, duodenal ischemia, and certain autoimmune diseases (e.g., Crohn’s disease). In some cases, gallstones impacted in the duodenum have also been related to perforation.[19]

Iatrogenic causes of perforation include endoscopy and surgery. Therapeutic endoscopic procedures, such as ERCP have a higher risk of causing perforation. Multiple classifications are used for ERCP-related perforations, such as Stapfer’s classification, Howard’s classification, and Enns’ classification.[18]Operative injury to the duodenum may not be apparent during the early postoperative period, manifesting later as delayed perforation due to duodenal wall coagulative necrosis. The main etiology is laparoscopic cholecystectomy. The mechanism of injury is usually related to thermal injury due to electrocautery or blunt or sharp dissection.[19]

The cardinal signs of perforated ulcer are sudden intense abdominal pain, accompanied by tachycardia and abdominal rigidity.[20] Perforated peptic ulcers manifest in 3 phases. Within the first 2 hours, the classic presentation is epigastric pain with tachycardia and cold extremities. During the second phase (hours 2 to 12), the pain becomes generalized, increases with movement, and rigidity develops. The third phase (>12 hours) is characterized by abdominal distention, fever, and hypotension.[20]

A timely upright chest x-ray (CXR) is an essential imaging test in acute upper abdominal pain patients. In patients with perforation, an upright CXR will demonstrate subdiaphragmatic free air in 75% of patients. However, a normal finding does not exclude perforation, especially during the early presentation. Stable patients with normal CXR and clinical findings suspicious of perforation may be further evaluated with a non-contrast CT scan. The diagnostic accuracy of the CT scan for perforated ulcers is around 98%.

In the case of ERCP-related perforation, the early presentation is often not specific. The cardinal signs mentioned above only manifest in a minority of cases. The most accurate way of detecting ERCP-related perforation is detecting the injury during the procedure itself. USG or CT scan may help in detecting perforation in suspected patients.

Treatment of duodenal perforation includes conservative, endoscopic, and surgical approaches. Conservative treatment starts with keeping the patient nil per os, fluid resuscitation, broad-spectrum antibiotics, gastric tube placement, intravenous proton pump inhibitors (PPI), and H. pylori eradication. Some ulcers may heal spontaneously: conservative therapy has been successful in 50-70% of patients with perforated ulcers.

Perforation location and size, continuity of the duodenum, contamination degree, and underlying cause determine the surgical technique required.

Simple Surgical Repair

Simple surgical repair is the mainstay of operative treatment. This involves primary suturing with or without an omental patch. An alternative is to use a pedunculated omental flap (Cellan-Jones repair) or a free omental patch (Graham patch) sutured over the perforation. Gelatin sponge and fibrin glue have been developed for suture-less techniques. There seems to be no significant difference in morbidity or mortality between these techniques. Simple surgical repair can be achieved via open surgery or laparoscopy.[19]

Abdominal Drain

Postoperative abdominal drainage is controversial. Literature does not show any benefit in preventing fluid collection or abscess formation. Abdominal drainage is also related to higher morbidity, such as infections at the drainage site.[19]

Pyloric Exclusion

Pyloric exclusion includes duodenal perforation repair, followed by gastrotomy, pylorus closing from the inside, and finally, a gastrojejunostomy formation. This procedure aims to divert gastric and biliary secretion from the duodenum. However, the benefits of this procedure have been debatable recently due to the high incidence of complications after surgery and longer hospital admission compared to simple surgical repair.[19]

Reconstructive Surgeries

A duodeno-duodenostomy may be needed for large perforation. If this procedure is unattainable, the alternative is performing a Roux-en-Y duodenojejunostomy. A Billroth II procedure may be required if the perforation occurs in the proximal duodenum. In cases with duodeno-pancreatic head destruction, a pancreaticoduodenectomy may be indicated.[19]

Tube Duodenostomy

Tube duodenostomy is a damage control procedure for large duodenal perforations when other techniques are not feasible due to the degree of injury, hemodynamic instability, or lack of expertise for complex reconstructions. A catheter is inserted into the perforation, around which the defect is sutured to stimulate directed fistula formation. The catheter is removed after six weeks. Enteral nutrition is given through a feeding jejunostomy tube.

Although rare, duodenal perforation following ERCP is a major complication that could be fatal if not quickly recognized and treated. The signs and symptoms may be nonspecific, notably in the immunocompromised and the elderly, making timely diagnosis challenging. Clinicians should always be mindful of this complication risk, as prompt diagnosis and treatment are essential in reducing morbidity and mortality.

1. Freeman, M.L. “Complications of Endoscopic Retrograde Cholangiopancreatography.” Techniques in Gastrointestinal Endoscopy, vol. 14, 2012, pp. 148–155.

2. Matthew, L. et al. “Complications Related to Endoscopic Retrograde Cholangiopancreatography: A Comprehensive Clinical Review.” Journal of Gastrointestinal and Liver Disease, 2009, pp. 73–82.

3. Lopez, P.P. et al. “Anatomy, Abdomen and Pelvis, Duodenum.” StatPearls, StatPearls Publishing, Treasure Island, August 2020.

4. Machado, N.O. “Management of Duodenal Perforation Post-Endoscopic Retrograde Cholangiopancreatography: When and Whom to Operate and What Factors Determine the Outcome? A Review Article.” JOP, vol. 13, no. 1, January 2012, pp. 18–25.

5. Møller, M.H. et al. “Multicentre Trial of a Perioperative Protocol to Reduce Mortality in Patients with Peptic Ulcer Perforation.” British Journal of Surgery, vol. 98, no. 6, June 2011, pp. 802–810.

6. Lau, J.Y. et al. “Systematic Review of the Epidemiology of Complicated Peptic Ulcer Disease: Incidence, Recurrence, Risk Factors and Mortality.” Digestion, vol. 84, no. 2, 2011, pp. 102–113.

7. Ansari, D. et al. “Diagnosis and Management of Duodenal Perforations: A Narrative Review.” Scandinavian Journal of Gastroenterology, vol. 54, no. 8, August 2019, pp. 939–944.

8. Lanas, A. et al. “Peptic Ulcer Disease.” The Lancet, vol. 390, no. 10094, August 2017, pp. 613–624.

9. Søreide, K. et al. “Perforated Peptic Ulcer.” The Lancet, vol. 386, no. 10000, September 2015, pp. 1288–1298.

10. Amini, A. and R.A. Lopez. “Duodenal Perforation.” StatPearls, StatPearls Publishing, Treasure Island, January 2021.

11. Zelickson, M.S. et al. “Helicobacter Pylori Is Not the Predominant Etiology for Peptic Ulcers Requiring Operation.” American Surgeon, vol. 77, no. 8, August 2011, pp. 1054–1060.

12. Søreide, K. et al. “Strategies to Improve the Outcome of Emergency Surgery for Perforated Peptic Ulcer.” British Journal of Surgery, vol. 101, no. 1, January 2014, pp. e51–e64.

13. Dubecz, A. et al. “Management of ERCP-Related Small Bowel Perforations: The Pivotal Role of Physical Investigation.” Canadian Journal of Surgery, vol. 55, no. 2, April 2012, pp. 99–104.

14. Rabie, M.E. et al. “Operative and Non-Operative Management of Endoscopic Retrograde Cholangiopancreatography-Associated Duodenal Injuries.” Annals of the Royal College of Surgeons of England, vol. 95, no. 4, May 2013, pp. 285–290.

15. Malhotra, A. et al. “Western Trauma Association Critical Decisions in Trauma: Diagnosis and Management of Duodenal Injuries.” Journal of Trauma and Acute Care Surgery, vol. 79, no. 6, December 2015, pp. 1096–1101.

16. Gardner, A.W. et al. “Double Duodenal Perforation Following Foreign Body Ingestion.” BMJ Case Reports, December 2017.

17. Machado, N.O. “Management of Duodenal Perforation Post-Endoscopic Retrograde Cholangiopancreatography: When and Whom to Operate and What Factors Determine the Outcome? A Review Article.” JOP, vol. 13, 2012, pp. 18–25.

18. Møller, M.H. et al. “Multicentre Trial of a Perioperative Protocol to Reduce Mortality in Patients with Peptic Ulcer Perforation.” British Journal of Surgery, vol. 98, 2011, pp. 802–810.

19. Lau, J.Y. et al. “Systematic Review of the Epidemiology of Complicated Peptic Ulcer Disease: Incidence, Recurrence, Risk Factors and Mortality.” Digestion, vol. 84, 2011, pp. 102–113.

20. Koc, B. et al. “Complications Following Endoscopic Retrograde Cholangiopancreatography: Minimal Invasive Surgical Recommendations.” PLoS One, vol. 9, no. 11, November 2014, e113073. https://doi.org/10.1371/journal.pone.0113073.