Bilateral Pneumothorax and Subcutaneous Emphysema following Endoscopic Retrograde Cholangiopancreatography: A Rare Complication

Endoscopic Retrograde Cholangiopancreatography (ERCP) is a widely used diagnostic and therapeutic modality in the management of biliary and pancreatic disease. Some of the complications of the procedure, although rare, may carry significant morbidity and mortality risks. We describe the case of a 68-year-old female who underwent elective ERCP for ductal stone clearance. Immediately postprocedure, the patient developed subcutaneous emphysema and bilateral pneumothoraces. Further imaging revealed the presence of free intra-abdominal air. The patient made a very quick recovery after bilateral chest drain insertion and no further intervention was required. We propose that pneumothorax, pneumomediastinum, and subcutaneous emphysema during ERCP, in the absence of duodenal perforation may be explained by leakage of air from a site of low resistance such as the sphincterotomy site, or as a result of copious Valsalva manoeuvres performed by a patient tolerating the procedure poorly.