Searching for a specific type of document on the internet is sometimes like looking for a needle in a haystack. If your pdf reader is displaying an error instead of opening a pdf file, chances are that the file is c. Management of perforation after endoscopic retrograde. Chest and abdominal radiographs are useful in assessing post ercp complications. A joint photographic experts group jpeg image is a compressed digital copy of a photograph or a scanned image. A rare case of duodenum perforation after biliary stenting. Open access recent advanced endoscopic management of. We report three cases, all with other features typical of nonaccidental injury. Pdf endoscopic retrograde cholangiopancreatography ercp has evolved from a diagnostic tool to primarily therapeutic procedure. Perforation after endoscopic retrograde cholangiopancreatography ercp is a rare complication, but it is associated with significant mortality. Most frequent post ercp perforation was stapfer type ii 58. Endoscopic retrograde cholangiopancreatography ercp with sphincterotomy is commonly used in the treatment of common bile duct stones. To combine pdf files into a single pdf document is easier than it looks.
The challenging diagnosis and treatment of duodenal. The interval between the perforation and the operation is of great significance the mortality rate increases dramatically with late surgical management 24 hours clinical and radiographic features can be used to determine the surgical or conservative treatment of ercp related duodenal perforations. Acute pancreatitis occurs in approximately 5% of diagnostic procedures and 10% of therapeutic procedures. The mortality rate in perforated patients is high, from 15% to 25% 6,7. Managing perforations related to endoscopic retrograde. Computed tomography ct is the best method for the diagnosis of duodenal perforation, detecting retroperitoneal air or liquid.
Several independent risk factors have been associated with pe even though considered safe, endoscopic retrograde cholangiopancreatography ercp is among the endoscopic procedures associated with the highest rate of complications. Several studies have sug gested surgical, endoscopic, radiologic or conservative management 3,4. Jan 24, 2014 background duodenal perforation is an uncommon complication of endoscopic retrograde cholangiopancreatography ercp and a rare complication of upper gastrointestinal endoscopy. Duodenal perforation is one of the most serious complications of endoscopic retrograde cholangiopancreatography ercp and is difficult to manage. Diagnostic delay is common, as the true history is concealed and signs may be minimal. We analyzed data pertaining to clinical details, management, and outcome.
Ercp induced duodenal perforation successfully treated with endoscopic pursestring suture. Adobe systems is a software manufacturer that has created many document and multimedia editing programs. Surgical management of duodenal perforations after ercp. Endoscopic retroperitoneal fatpexy of a large ercp related jejunal perforation by using a new overthescope clip device in billroth ii anatomy. Amylase and lipase elevations often occur after ercp even in. A pdf file is a portable document format file, developed by adobe systems. Pneumoretroperitoneum secondary to duodenal perforation after. Pneumoretroperitoneum secondary to duodenal perforation.
Surgery remains the mainstay of treatment for perforated duodenal diverticula. Perforation is a rare but potentially lethal complication of duodenal diverticular disease. This has led some authors to recommended early operation in all duodenal perforations. Pneumopericardium, pneumomediastinum, pneumoretroperitoneum. One of the fun things about computers is playing with programs like paint. Retroperitoneal air after ercp with sphincterotomy. Pdf is a hugely popular format for documents simply because it is independent of the hardware or application used to create that file. Luckily, there are lots of free and paid tools that can compress a pdf file in just a few easy steps. It can be a result of both intraperitoneal duodenal perforation 30 and retroperitoneal duodenal perforation 29. The timing of diagnosis is critical for management and patient outcome 810.
Iatrogenic duodenal injuries suny downstate medical center. Ercpinduced duodenal perforation successfully treated with. You can use the tools in paint to add something to a different document. Even though considered safe, endoscopic retrograde cholangiopancreatography ercp is among the endoscopic procedures associated with the highest rate of complications. Management of duodenal perforations after endoscopic. There is no consensus to guide the clinician on the management of ercp related perforations, with particular controversy surrounding the immediate surgical management of postprocedurally detected duodenal perforation because of overextension of a sphincterotomy. Management of perforation after endoscopic retrograde journalagent.
A 42yearold lady with abdominal pain, gallstones and obstructive jaundice underwent an endoscopic retrograde cholangiopancreatography ercp and sphincterotomy for relief of her symptoms. Though their analysis was not specifically limited to duodenal perforations, enns et al identified a number of risk factors for perforation during ercp including prolonged procedures odds ratio or 1. Pdf tension pneumothorax, unusual presentation of postercp. Most of the duodenal diverticula are asymptomatic, incidental findings.
Pdf the management of large perforations of duodenal ulcers. The female patient in this study suffered a duodenal perforation after biliary stenting under ercp. This study describes a case of duodenum perforation after biliary stenting under ercp for the first time. Endoscopic treatment of ercprelated duodenal perforation. Evidencebased strategies are lacking regarding the appropriate management of duodenal perforations complicating endoscopic retrograde cholangiopancreatography ercp combined with endoscopic sphincterotomy es. Most are minor perforations that settle with conservative management. Acute iatrogenic perforation during endoscopy is defined as the presence of gas or luminal contents outside the gastrointestinal tract 7. Management of duodenal perforation postendoscopic retrograde. The patient underwent emergency surgery after which she was admitted to the icu but her evolution was torpid, and she died.
This article explains what pdfs are, how to open one, all the different ways. Perforation was suspected immediately post ercp in one case and, in the second case, perforation was evident during ercp and a biliary stent was inserted. Dec 01, 2017 the most frequent post ercp perforation was stapfer type ii 177 patients, 58. This study evaluated the early management experience of these perforations. With this, the complexity of the procedure and risk of complication including duodenal perforation have increased. After successful medical management of a patient with a clinical picture suggestive of post sphincterotomy duodenal perforation, in which a computerized axial tomography cat scan of the abdomen revealed the presence of subcutaneous emphysema and retroperitoneal air, concern arose as to the frequency of pneumoretroperitoneum following endoscopic retrograde. Some advocate a nonsurgical approach to management in certain select patients. Endoscopic retrograde cholangiopancreatography ercp is the most suitable test to diagnose and treat bile duct pathology. The treatment strategies for such perforations are diverse and continue to be debated. Stapfer classification of ercp related duodenal perforations was used. Fortythree percent of patients with perforation revealed a concurrent post ercp pancreatitis. Endoscopic treatment of a large duodenal perforation.
Pancreatitis introduction post ercp pancreatitis pep is the most common serious adverse event attributed to the procedure, resulting in annual estimated costs exceeding 150 million dollars in the united states. Other complications of ercp are duodenal hemorrhage and cholangitis. A 67yearold female patient was transferred to the emergency department of first hospital of china medical university after experiencing whole abdominal pain for 6 hours. The reason for a pdf file not to open on a computer can either be a problem with the pdf file itself, an issue with password protection or noncompliance w the reason for a pdf file not to open on a computer can either be a problem with the. Recently, endoscopic pursestring suture, using endoloops with endoclips, is a relatively new technology. Duodenal injury under endoscopic retrograde cholangiopancreatography ercp is extremely rare. By michelle rae uy 24 january 2020 knowing how to combine pdf files isnt reserved. Conservative management of duodenal perforation following. The most common causes of post ercp pain are acute pancreatitis and duodenal perforation.
Duodenal perforations are extremely rare in the context of basic upper endoscopy, and usually occur in the context of duodenal dilatation, endoscopy in a patient with altered anatomy, when applying advanced techniques such as emr or esd, or in advanced procedures such as ercp. During the operation, a small amount of yellowwhite exudate was observed around the liver and duodenum, and the biliary stent was found to have caused a small perforation measuring 0. During balloon sweepings the scope snapped and hit the duodenal wall opposite to the ampullary area. Review of duodenal perforations after endoscopic retrograde. Pdf tension pneumothorax, unusual presentation of post. In total, 15 of 29 patients with ercp perforation were operated on. Management of duodenal perforation after endoscopic. Background duodenal perforation is an uncommon complication of endoscopic retrograde cholangiopancreatography ercp and a rare complication of upper gastrointestinal endoscopy. Most electronic documents such as software manuals, hardware manuals and ebooks come in the pdf portable document format file format. Jan 08, 2020 background the duodenum is a common site for diverticulum formation. Perforation is a rare but serious adverse event of ercp. Although duodenal perforations secondary to the biliary plastic stent are quite rare, they can be lifethreatening. For example, epigastric abdominal pain after ercp can occur from other causes, such as duodenal perforation, excessive contrast injection, or air insufflation.
It was managed with a biliary stent and medical treatment, and the patient. We present the case of a patient with a duodenal perforation following ercp type ii. Duodenum perforation an overview sciencedirect topics. Perforation is one of the most dreaded complications of ercp. Clinical manifestations are similar to those that appear in pancreatitis i. Pdf file or convert a pdf file to docx, jpg, or other file format. Ercp complications and challenges in their diagnosis and. Early management experience of perforation after ercp. Vs the risk of a perforation occurring during an ercp is fairly uncommon. A clinical and biochemical diagnosis of post ercp pancreatitis and a ct abdopelvis was requested. Perforation ercp related perforation occurs in 0 3%related perforation occurs in 0. Duodenal perforations secondary to a migrated biliary plastic.
There are various clinical courses and presentations of post ercp duodenal perforations depending on the extent of the perforation. Duodenal perforations are extremely rare in the context of basic upper endoscopy, and usually occur in the context of duodenal dilatation, endoscopy in a patient with altered anatomy, when applying advanced techniques such as emr or esd, or in advanced procedures such as ercp and eus. Pdf management of duodenal perforation postendoscopic. Management of post ercp perforations must be individualized for each patient, depending on the clinical situation. Read on to find out just how to combine multiple pdf files on macos and windows 10. This means it can be viewed across multiple devices, regardless of the underlying operating system. Perforation of approximately 1 cm is evident in the duodenal wall contralateral to the papilla over a duodenal diverticulum. Algorithm for the management of ercprelated perforations. Context endoscopic retrograde cholangiopancreatography ercp has evolved from a diagnostic tool to primarily therapeutic procedure. The paint program can help you make new image files, but it cannot open document or pdf file. Ercp in one case and, in the second case, perforation was evident during ercp and a biliary stent was inserted. Management of duodenal perforation after endoscopic retrograde. Recently, endoscopic pursestring suture, using endoloops with endoclips, is a relatively new technology and has provided good clinical results. Duodenal perforation is a rare, life threatening injury associated with nonaccidental blunt abdominal trauma.
Pneumothorax is a serious but rare complication of ercp 2831. In recent years, a few cases were successfully managed either conservatively or with. Between november 2003 and december 2011, a total of 8504 ercps were performed at our regional endoscopy center. A pdf portable document format is a widely popular type of document format created by adobe. A few perforations however result in lifethreatening retroperitoneal necrosis and require surgical intervention. Ercpinduced duodenal perforation successfully treated. In duodenal perforation, ct may reveal extraluminal air or. An oversized pdf file can be hard to send through email and may not upload onto certain file managers. Of the three duodenal perforations, all required operation and one patient died. May 12, 2020 background endoscopic retrograde biliary drainage erbd is the most frequently performed procedure for treating benign or malignant biliary obstruction. Duodenal perforations secondary to a migrated biliary. The perforation of the digestive tract after endoscopic retrograde cholangiopancreatography ercp is a rare complication. Duodenal perforation post ercp is rare, occurring in 1% range 0.
Double contrast computed tomography is the most sensitive investigation to confirm clinical suspicion. Pancreatic enhancement is diminished in areas of glandular necrosis. Endoscopic retrograde cholangiopancreatography ercp has evolved from a diagnostic tool to primarily therapeutic procedure. Apr 01, 2019 it is important for endoscopists to be cognizant of the patient and procedurerelated risk factors leading to duodenal perforation.
The 2 complications that occur less frequently are postsphincterotomy bleeding and ercp related duodenal perforations figure 1. Surgery remains the best option for the treatment of post ercp perforations, although conservative medical management is an option to be assessed, assuming that if it fails, delaying su. In severe pancreatitis, the pancreas is enlarged and enhances heterogeneously at ct. Even now, management of ercp associated duodenal perfo ration remains controversial. Risk factors are sphincter of oddi dysfunction and young age.
We report two cases of duodenal perforations following endoscopic sphincterotomy. The patient presented the following day with abdominal pain. Endoscopy shows a high sensitivity and specificity for diagnosis of iatrogenic perforation 11. Post ercp pancreatitis pep is the most common complication of ercp. In stable patients, conservative management of duodenal perforation post ercp is preferred. Perforation recognized or suspected at ercp periampullary perforation guidewire perforation duodenal perforation npo antibiotics clinical observation biliary stent or nasobiliary tube npo, antibiotics ct. The group demonstrated that, of the 2874 patients 48% who had a sphincterotomy, 40 patients 0. The cause for duodenal perforation was duodenal ulcer n 25, 45. The incidence of perforation post ercp has been investigated by howard et al, who performed a retrospective analysis of 6040 ercps. Surgical or endoscopic management for postercp large.
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