Fatal pneumoperitoneum following endoscopic retrograde cholangiopancreatography confirmed by post-mortem computed tomography

We present the case of an 80-year-old female who died in intensive care after unsuccessful resuscitation within 4 h after endoscopic retrograde cholangiopancreatography (ERCP).The patient was scheduled for an ERCP because of intermittent abdominal pain, hyperbilirubinemia, elevated liver enzymes, and dilated intrahepatic ducts diagnosed by abdominal contrast computed tomography. She had several comorbidities and her clinical history included dementia, breast cancer, diabetes mellitus, and chronic renal insufficiency. The patient remained stable and no complications were noted by the physicians throughout the ERCP with sphincterotomy for the removal of bile stones (up to 15 mm diameter) from the intrahepatic ducts. The procedure lasted for approximately 20 min. Immediately after the intervention, she developed dyspnea, tachycardia, and peripheral cyanosis and physical examination showed abdominal distension. The patient deteriorated rapidly and died within 4 h despite extensive resuscitation attempts. Radiological imaging and exploratory surgery were not performed in the hospital. A medicolegal autopsy and whole-body post-mortem computed tomography (PMCT, 4-rowmultidetector CT; PhilipsMX 8000; scanning parameters:mAs: 280; kVp: 120; slice thickness: 3.2/1.6 mm) were performed 3 days after death, at which time, the body showed no putrefaction. External examination revealed firm abdominal distension in an obese female (body mass index, 39 kg/m) (Fig. 1). Petechial hemorrhages were observed on the facial skin, eyelids, and conjunctivae (Fig. 2). PMCT demonstrated massive pneumoperitoneum and extreme elevation of the diaphragm (Fig. 3) and a total volume of approximately 11L of intraperitoneal air was calculated using volume rendering (standard DICOM viewer OsiriX v. 3.7.1, 32-bit, OsiriX Foundation, Geneve, Switzerland, http://www.osirixviewer.com). Before dissection, an intraperitoneal pressure of 27 mm Hg was measured using a manometer. The pneumoperitoneum was confirmed by autopsy. Opening of the abdominal wall resulted in the release of an inodorous gas and spontaneous regression of the abdominal wall. As demonstrated by the autopsy, the pneumoperitoneum resulted from an anterior duodenal wall perforation of 1.5 9 1.5 cm that was located 2.5 cm from the major duodenal papilla (Figs. 4, 5). Mild hemorrhage was noted around the perforation and no signs of inflammation or other internal organ injury were seen. Three gall stones were found: one in the ampulla (diameter, 14 mm) and two in the duodenum (diameter, 10 mm). The external bile duct was dilated to 3.2 cm. All of the findings, including forensic investigations, verified that death was due to respiratory failure caused by upper abdominal congestion from a tension pneumoperitoneum resulting from duodenal wall perforation during ERCP.