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Case Presentation Post ERCP Perforation From uptodate

Case Presentation Post ERCP Perforation From www.uptodate.com. Dr.Mohammad Amin Mirza General Surgery Resident Saudi Board in GS(R1) Al-Noor Specialist Hospital Makkah - 2003. B . S Age : 42 y.o Gender : Female Saudi Date of admission : 28 – 06 – 1424 AH

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Case Presentation Post ERCP Perforation From uptodate

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  1. Case PresentationPost ERCP PerforationFrom www.uptodate.com Dr.Mohammad Amin Mirza General Surgery Resident Saudi Board in GS(R1) Al-Noor Specialist Hospital Makkah - 2003

  2. . • B . S • Age : 42 y.o Gender : Female Saudi • Date of admission : 28 – 06 – 1424 AH • Social status : Married , House wife (10 children's ) • Family history : Mother is diabetic

  3. . • Admitted through OPD with typical history of calculuar cholecystitis . • H/O itching ; dark color of urine ; normal stool . • No H/O jaundice • On examination : - Not jaundice . - Chest & CVS – NAD - Abdomen : Soft lax , tender RHC , paraumblical bulging (hernia)

  4. . • USG abdomen (19 – 06 – 24 ) : Multiple stones in GB with dilated CBD (9mm) , up to 13 mm it distal end & faint showing seen distally. Small stones ? or sludge , needs further evaluation . No intrahepatic biliary tree dilatation . • Chemistry : normal on admission .

  5. Indication For ERCP:- Dilated CBD , containing ? stones- H/O itching ; dark color of urine ERCP done at 29 – 06 – 1424 AH : • Difficult canulation of the ampulla of Vater , • Stricture at lower end of CBD • Duadenal diverticulum • Precut sphyncterotomy done • Bile flowing freely

  6. Pt received by Ward nurse at 14:50She noticed that Pt is having face puffiness, gradually increasing abdominal distension, & swelling of the neck with vomiting content of bloody color • Surgical Emphysema • Vitally stable Surgical specialist has seen the Pt and informed the consultant on call. Pt kept NPO , with IVF (3 L\hr) O² 10 L\m

  7. - USG abdomen : intraperitoneal air, No free fluid intra abdominal, subcut emphysema - CT chest : Bilateral pneumothorax, extensive emphysema retroperitoneal (abdomen & pelvis) Intra abdominal air (large amount); no esophageal injury.-Gastrographin swallow : no esophageal rupture, sever GE reflux, contrast not progressing from antral region on ward for 45 min . -Consulted Chest surgeon ,, who inserted Rt ICT . and later Lt ICT

  8. Pt Taken to OR for urgent laparotomy at 21:00 • Exploratory laparotomy: • Cholecyctectomy, • Sphyncteroplasty of sphyncter of Oddi, • T-Tube insertion into CBD, • Feeding jejunostomy tube, • Repair of PUH.

  9. Post operatively Pt was in ICU for close observation for 24 hrs • Pt is stable • Doing well • Shifted to FSW and remains stable, & improving.

  10. Patients progress • MRSA – wound infection . (POD 8) • Abdominal wall collection which is drained and treated by antibiotics according to C/S with dressing BID (POD 27) • T-Tube is removed (T-Tube Nil , Drain – 200 ml ) and T-Tube cholangiogramm is showing free passage of the die into Duodenum , and no leakage • US-guided aspiration of retroperitoneal abscess-210cc. C\S Ca.Albicans.

  11. Patient is discharged from the hospital in good condition to be followed in surgical OPDFirst days of Ramadhan 1424

  12. Overview of complications of E R C P&endoscopic biliary sphincterotomy

  13. Classification of complications

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  17. Risk factors Overall perforations: • Pt related : -Sphincter of Oddi dysfunction - A dilated common bile duct. - Distal CBD Stricture . . Procedure related: - Sphincterotomy - Longer duration of the procedure - Biliary strictuer dilatation

  18. Risk factors • Risk factors for bowel wall perforation : - Patients who have stenosis in the upper gastrointestinal tract or bile ducts - patients who have undergone gastric resection (Billroth II gastrectomy)

  19. Risk factors • Risk factors for retroperitoneal perforation: - precut sphincterotomy and larger sphincterotomies particularly those that are created outside of the usually recommended landmarks (11 to 1 o'clock) - small caliber bile duct - the presence of a peripapillary diverticulum - intramural injection of contrast

  20. PREVENTION • The risk of perforation can be minimized when ERCP is performed by well-trained endoscopists and assistants abiding by the following technique-related principles: • Proper orientation of the sphincterotome between 11 and 1 o'clock • Step-by-step incision • Avoiding a "zipper" cut • Sphincterotomy length tailored to the size of papilla, bile duct, and eventual stone • Judicious use of precut • Appropriate technique in cases of anatomical variants such as peripapillary diverticula and Billroth II gastrectomy

  21. MANAGEMENT • NPO ,proper hydration , NGT , or naso-duodenal tube , & IV antibiotics . • Patients with esophageal and free abdominal gastric, jejunal, or duodenal perforation usually require surgery: - choledochotomy with stone extraction and T-tube drainage, - repair of the perforation, - drainage of abscess or phlegmon, - choledochojejunostomy, or pancreatoduodenectomy - nasobiliary tube (during ERCP) - Percutaneous drainage - TPN for Pt who are expected to remain on bowel rest for at least one week

  22. Conclusion

  23. Close observation of patients who underwent ERCP at least 6 hours after procedure is mandatory by the resident on duty , especially the cases which had difficulty in the procedure

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