Life-Threatening Duodenal Perforation Following Endoscopic Retrograde Cholangiopancreatography in an Elderly Patient: A Case Report

Endoscopic retrograde cholangiopancreatography (ERCP) is a valuable diagnostic and therapeutic procedure for pancreaticobiliary disorders, but may rarely result in severe complications such as duodenal perforation. A 77-year-old man with hypertension, diabetes, dyslipidemia, and benign prostatic hyperplasia presented with painless obstructive jaundice for a duration of four weeks. Laboratory tests showed a cholestatic pattern and elevated carbohydrate antigen 19-9. Magnetic resonance cholangiopancreatography (MRCP) demonstrated marked dilation of the common bile duct with abrupt distal tapering, mild pancreatic duct dilation, and a periampullary diverticulum, suggesting a periampullary neoplastic lesion or fibrotic stenosis. An ERCP was performed for diagnostic clarification and potential therapeutic decompression. Difficult cannulation required a precut sphincterotomy, after which a duodenal perforation was suspected. Post-procedure, the patient developed extensive subcutaneous, retroperitoneal, and mediastinal emphysema, pneumopericardium, and bilateral pneumothoraces. A CT confirmed free intraperitoneal air and contrast extravasation in the retroperitoneal space anterior to the left renal fascia, consistent with a perforation of the third portion of the duodenum. Emergency laparotomy identified and repaired the defect with a Graham patch. Despite intensive care with broad-spectrum antimicrobials and vasopressors, the patient developed septic shock and multi-organ failure and died nine days later. This case underscores the catastrophic potential of ERCP-related duodenal perforation and the importance of early CT diagnosis and individualized intervention in high-risk patients.