Complications of Endoscopic Retrograde Cholangiopancreatography: Spectrum of Abnormalities Demonstrated with CT1
Harpreet K. Pannu, MD and
Elliot K. Fishman, MD
1 From the Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University, Baltimore, Md. Presented as a scientific exhibit at the 1999 RSNA scientific assembly. Received April 18, 2000; revision requested June 21; final revision received May 3, 2001; accepted May 3. Address correspondence to H.K.P., Department of Radiology, Johns Hopkins Hospital, 600 N Wolfe St, Baltimore, MD 21287 (e-mail: hpannu@jhmi.edu).
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Figure 1a. Post-ERCP pancreatitis in a 50-year-old man. ERCP was performed to check for a mass in the pancreatic tail, and the entire pancreatic duct was well opacified. The patient was readmitted 3 days after ERCP with abdominal pain and low-grade fever. CT was performed with oral and intravenous contrast material. (a) CT scan shows heterogeneous attenuation of the pancreas. Low-attenuation areas (*) suggest necrosis. Stranding of the peripancreatic fat is due to inflammation. There is thickening of the wall of the antrum of the stomach (arrow) secondary to local inflammation. (b) CT scan obtained inferior to a shows extensive stranding of the fat and thickening of the Gerota fascia on the right side (arrow). (c) CT scan shows fluid (arrow) in the dependent portion of the pelvis, a finding compatible with ascites.
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Figure 1b. Post-ERCP pancreatitis in a 50-year-old man. ERCP was performed to check for a mass in the pancreatic tail, and the entire pancreatic duct was well opacified. The patient was readmitted 3 days after ERCP with abdominal pain and low-grade fever. CT was performed with oral and intravenous contrast material. (a) CT scan shows heterogeneous attenuation of the pancreas. Low-attenuation areas (*) suggest necrosis. Stranding of the peripancreatic fat is due to inflammation. There is thickening of the wall of the antrum of the stomach (arrow) secondary to local inflammation. (b) CT scan obtained inferior to a shows extensive stranding of the fat and thickening of the Gerota fascia on the right side (arrow). (c) CT scan shows fluid (arrow) in the dependent portion of the pelvis, a finding compatible with ascites.
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Figure 1c. Post-ERCP pancreatitis in a 50-year-old man. ERCP was performed to check for a mass in the pancreatic tail, and the entire pancreatic duct was well opacified. The patient was readmitted 3 days after ERCP with abdominal pain and low-grade fever. CT was performed with oral and intravenous contrast material. (a) CT scan shows heterogeneous attenuation of the pancreas. Low-attenuation areas (*) suggest necrosis. Stranding of the peripancreatic fat is due to inflammation. There is thickening of the wall of the antrum of the stomach (arrow) secondary to local inflammation. (b) CT scan obtained inferior to a shows extensive stranding of the fat and thickening of the Gerota fascia on the right side (arrow). (c) CT scan shows fluid (arrow) in the dependent portion of the pelvis, a finding compatible with ascites.
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Figure 2a. Renal involvement by ERCP-induced pancreatitis in a 75-year-old woman. ERCP was performed for a dilated common bile duct, and the duct was "swept" for stones. After the procedure, the patient had clinically evident pancreatitis, which was also demonstrated at multiple CT studies. She developed a perinephric fluid collection, which showed no evidence of infection at fine-needle aspiration. The collection was not drained and persisted for several weeks. CT was performed with intravenous contrast material 28 days after ERCP. (a) CT scan shows stranding of the fat (arrow) adjacent to the head of the pancreas and the duodenum. A heterogeneous fluid collection is present in the perirenal space (*). (b) CT scan obtained inferior to a shows the fluid collection displacing the intestine and abutting the psoas muscle (arrow).
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Figure 2b. Renal involvement by ERCP-induced pancreatitis in a 75-year-old woman. ERCP was performed for a dilated common bile duct, and the duct was "swept" for stones. After the procedure, the patient had clinically evident pancreatitis, which was also demonstrated at multiple CT studies. She developed a perinephric fluid collection, which showed no evidence of infection at fine-needle aspiration. The collection was not drained and persisted for several weeks. CT was performed with intravenous contrast material 28 days after ERCP. (a) CT scan shows stranding of the fat (arrow) adjacent to the head of the pancreas and the duodenum. A heterogeneous fluid collection is present in the perirenal space (*). (b) CT scan obtained inferior to a shows the fluid collection displacing the intestine and abutting the psoas muscle (arrow).
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Figure 3. Colonic involvement by ERCP-induced pancreatitis due to retroperitoneal spread of inflammation in a 38-year-old woman. Multiple attempts were made to cannulate the pancreatic duct without success. The patient had postprocedure pain and an elevated amylase level with imaging evidence of acute pancreatitis. CT was performed with oral and intravenous contrast material 1 day after ERCP. CT scan shows inflammatory change (*) in the retroperitoneum abutting the ascending colon. The wall of the ascending colon is thickened (arrow) due to dissection of peripancreatic fluid and inflammation along the anterior pararenal space into the paracolic gutter to surround the cecum and ascending colon. The patient was treated with medical therapy, and follow-up CT performed 3 weeks later showed a decrease in colonic inflammation.
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Figure 4a. Perforation of the right hepatic duct in a 35-year-old man with a history of sclerosing cholangitis. Dilation of the common bile duct was performed for a stricture. Owing to persistent pain, fever, and retroperitoneal fluid at CT, repeat ERCP was performed and showed leakage of contrast material from the right hepatic duct. A stent was placed, and the patient recovered within 1 week. CT was performed with oral and intravenous contrast material 2 days after ERCP. (a) CT scan shows fluid and extensive inflammation in the retroperitoneum due to bile leakage. The right ureter is surrounded (open arrow). The fluid tracked inferiorly from the gallbladder fossa. Solid arrow = left ureter. (b) CT scan shows inflammatory change and fluid in the presacral space (*). Arrow = rectum.
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Figure 4b. Perforation of the right hepatic duct in a 35-year-old man with a history of sclerosing cholangitis. Dilation of the common bile duct was performed for a stricture. Owing to persistent pain, fever, and retroperitoneal fluid at CT, repeat ERCP was performed and showed leakage of contrast material from the right hepatic duct. A stent was placed, and the patient recovered within 1 week. CT was performed with oral and intravenous contrast material 2 days after ERCP. (a) CT scan shows fluid and extensive inflammation in the retroperitoneum due to bile leakage. The right ureter is surrounded (open arrow). The fluid tracked inferiorly from the gallbladder fossa. Solid arrow = left ureter. (b) CT scan shows inflammatory change and fluid in the presacral space (*). Arrow = rectum.
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Figure 5. Intramural duodenal air after ERCP in a 55-year-old woman. ERCP was performed for evaluation of an ampullary tumor. Cannulation of the common bile duct was unsuccessful, and extravasation of contrast material from the duodenum was seen during the procedure. CT was performed with oral and intravenous contrast material 3 days after ERCP. CT scan shows air (arrow) in the dependent wall of the duodenum, which represents pneumatosis. The common bile duct is dilated, a finding compatible with the history of ampullary tumor. The patient was treated medically, and repeat CT performed 11 days later showed no evidence of an abscess.
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Figure 6a. Duodenal perforation after ERCP in a 49-year-old woman. ERCP was performed for evaluation of right upper quadrant pain and revealed a stricture in the common bile duct and nonfilling of the gallbladder, findings compatible with acute cholecystitis. The patient had pain immediately after the procedure and a significant amount of free air. CT was performed without contrast material on the day of ERCP. (a) CT scan obtained with a soft-tissue window shows free air (*) diffusely in the peritoneal cavity, retroperitoneum, and subcutaneous tissues. (b) CT scan obtained inferior to a shows extensive free air in the root of the mesentery (arrow). Air also dissected superiorly into the mediastinum and right pleural cavity. (c) Follow-up CT scan obtained 2 days later at the same level as in a shows a significant decrease in the amount of free air (*). There is thickening of the wall of the gallbladder (arrow) due to cholecystitis. The patient recovered within a few days with conservative treatment.
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Figure 6b. Duodenal perforation after ERCP in a 49-year-old woman. ERCP was performed for evaluation of right upper quadrant pain and revealed a stricture in the common bile duct and nonfilling of the gallbladder, findings compatible with acute cholecystitis. The patient had pain immediately after the procedure and a significant amount of free air. CT was performed without contrast material on the day of ERCP. (a) CT scan obtained with a soft-tissue window shows free air (*) diffusely in the peritoneal cavity, retroperitoneum, and subcutaneous tissues. (b) CT scan obtained inferior to a shows extensive free air in the root of the mesentery (arrow). Air also dissected superiorly into the mediastinum and right pleural cavity. (c) Follow-up CT scan obtained 2 days later at the same level as in a shows a significant decrease in the amount of free air (*). There is thickening of the wall of the gallbladder (arrow) due to cholecystitis. The patient recovered within a few days with conservative treatment.
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Figure 6c. Duodenal perforation after ERCP in a 49-year-old woman. ERCP was performed for evaluation of right upper quadrant pain and revealed a stricture in the common bile duct and nonfilling of the gallbladder, findings compatible with acute cholecystitis. The patient had pain immediately after the procedure and a significant amount of free air. CT was performed without contrast material on the day of ERCP. (a) CT scan obtained with a soft-tissue window shows free air (*) diffusely in the peritoneal cavity, retroperitoneum, and subcutaneous tissues. (b) CT scan obtained inferior to a shows extensive free air in the root of the mesentery (arrow). Air also dissected superiorly into the mediastinum and right pleural cavity. (c) Follow-up CT scan obtained 2 days later at the same level as in a shows a significant decrease in the amount of free air (*). There is thickening of the wall of the gallbladder (arrow) due to cholecystitis. The patient recovered within a few days with conservative treatment.
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Figure 7. Duodenitis after ERCP in a 37-year-old man. Cannulation of the common bile duct was difficult, and sphincterotomy could not be performed. The patient experienced pain and vomiting after the procedure and recovered within 10 days with conservative treatment. CT was performed with oral and intravenous contrast material on the day of ERCP. CT scan shows marked thickening of the wall of the duodenum (arrow) secondary to inflammation from ERCP. There is also fluid in the right perirenal space and thickening of the Gerota fascia.
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Figure 8. Duodenal perforation with air and fluid leakage in a 51-year-old woman. The patient underwent ERCP and sphincterotomy and developed postprocedure abdominal pain. Initial CT showed free retroperitoneal air. Repeat CT showed retroperitoneal fluid and a decrease in free air. CT scan obtained with oral and intravenous contrast material 5 days after ERCP shows minimal free air (arrow) and free fluid (*) in the retroperitoneum. The patient was treated conservatively and discharged after 10 days.
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Figure 9a. Fluid collection secondary to duodenal perforation in a 79-year-old woman. The patient underwent sphincterotomy and placement of a stent in the pancreatic duct. CT was performed with oral contrast material 7 days after ERCP. (a) CT scan shows thickening of the wall of the duodenum (solid arrow). An extraluminal collection of air and contrast material lies posterior to the duodenum (open arrow). There is thickening of the Gerota fascia on the right side. (b) CT scan obtained inferior to a shows fluid in the right anterior pararenal space (arrow), a finding compatible with leakage of enteric contents from the duodenum. The perforation was treated conservatively, and follow-up CT did not show progression of the fluid collection. The patient recovered within 3 weeks.
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Figure 9b. Fluid collection secondary to duodenal perforation in a 79-year-old woman. The patient underwent sphincterotomy and placement of a stent in the pancreatic duct. CT was performed with oral contrast material 7 days after ERCP. (a) CT scan shows thickening of the wall of the duodenum (solid arrow). An extraluminal collection of air and contrast material lies posterior to the duodenum (open arrow). There is thickening of the Gerota fascia on the right side. (b) CT scan obtained inferior to a shows fluid in the right anterior pararenal space (arrow), a finding compatible with leakage of enteric contents from the duodenum. The perforation was treated conservatively, and follow-up CT did not show progression of the fluid collection. The patient recovered within 3 weeks.
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Figure 10a. Hemorrhage and perforation after ERCP in a 67-year-old woman. Cannulation of the common bile duct was unsuccessful, and the patient experienced pain after the procedure. CT was performed with intravenous contrast material on the day of ERCP. (a) CT scan shows free retroperitoneal air (solid arrow) between the duodenum and pancreatic head and just posterior to the gastroduodenal artery (open arrow). The small amount of fluid and the stranding of fat in the right anterior pararenal space (*) are secondary to inflammation. The common bile duct is dilated. (b) CT scan obtained inferior to a shows a high-attenuation hematoma (arrow) between the duodenum and pancreas. (c) CT scan obtained inferior to b shows a high-attenuation mass (arrow) that appears to be abutting the lumen of the duodenum, a finding compatible with an intramural hematoma. The patient was treated conservatively and recovered within 3 days.
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Figure 10b. Hemorrhage and perforation after ERCP in a 67-year-old woman. Cannulation of the common bile duct was unsuccessful, and the patient experienced pain after the procedure. CT was performed with intravenous contrast material on the day of ERCP. (a) CT scan shows free retroperitoneal air (solid arrow) between the duodenum and pancreatic head and just posterior to the gastroduodenal artery (open arrow). The small amount of fluid and the stranding of fat in the right anterior pararenal space (*) are secondary to inflammation. The common bile duct is dilated. (b) CT scan obtained inferior to a shows a high-attenuation hematoma (arrow) between the duodenum and pancreas. (c) CT scan obtained inferior to b shows a high-attenuation mass (arrow) that appears to be abutting the lumen of the duodenum, a finding compatible with an intramural hematoma. The patient was treated conservatively and recovered within 3 days.
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Figure 10c. Hemorrhage and perforation after ERCP in a 67-year-old woman. Cannulation of the common bile duct was unsuccessful, and the patient experienced pain after the procedure. CT was performed with intravenous contrast material on the day of ERCP. (a) CT scan shows free retroperitoneal air (solid arrow) between the duodenum and pancreatic head and just posterior to the gastroduodenal artery (open arrow). The small amount of fluid and the stranding of fat in the right anterior pararenal space (*) are secondary to inflammation. The common bile duct is dilated. (b) CT scan obtained inferior to a shows a high-attenuation hematoma (arrow) between the duodenum and pancreas. (c) CT scan obtained inferior to b shows a high-attenuation mass (arrow) that appears to be abutting the lumen of the duodenum, a finding compatible with an intramural hematoma. The patient was treated conservatively and recovered within 3 days.
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Figure 11a. Stent misplacement or migration in a 23-year-old man with a history of common bile duct stones. CT was performed with intravenous contrast material 1 day after ERCP. (a) CT scan shows a linear area of increased attenuation (arrow) in the right lobe of the liver, which represents a biliary stent. (b) CT scan obtained inferior to a shows the tip of the stent in the proximal common bile duct (solid arrow). The contrast material in the duct (open arrow) and gallbladder is from the recent ERCP. The stranding of the adjacent fat is due to inflammatory change.
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Figure 11b. Stent misplacement or migration in a 23-year-old man with a history of common bile duct stones. CT was performed with intravenous contrast material 1 day after ERCP. (a) CT scan shows a linear area of increased attenuation (arrow) in the right lobe of the liver, which represents a biliary stent. (b) CT scan obtained inferior to a shows the tip of the stent in the proximal common bile duct (solid arrow). The contrast material in the duct (open arrow) and gallbladder is from the recent ERCP. The stranding of the adjacent fat is due to inflammatory change.
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Copyright © 2001 by the Radiological Society of North America.
