Pneumoperitoneum caused by gastroscopy in a jaundiced patient treated endoscopically after initial percutaneous approach.

structive jaundice, who had undergone placement of a percutaneous drainage catheter (10−Fr internal/external cathe− ter), was admitted for endoscopic retro− grade cholangiopancreatography (ERCP). The cholangiogram revealed an irregular stricture of the distal common bile duct. A hydrophilic guide wire was inserted across the transhepatic drainage and re− covered endoscopically; we removed the percutaneous drain, performed a biliary sphincterotomy, and inserted an 8−cm Zilver metallic stent (Wilson−Cook Medi− cal Inc., Winston−Salem, North Carolina, USA). Three days after ERCP, the patient underwent esophagogastroduodenosco− py with duodenal biopsies taken for his− tological analysis; the latter identified an adenocarcinoma. Immediately after eso− phagogastroduodenoscopy the patient developed acute abdominal pain. A CT scan (l" Fig. 1) revealed free air in the ab− domen and ascites around the spleen, in the right laterocolic space, and among the jejunal loops. The patient underwent urgent laparotomy but no bowel or bilia− ry perforation was revealed. Intraopera− tive cholangiography showed correct working of the biliary stent, but free pas− sage of contrast medium was observed through a fistula where the percutaneous drain had previously been. A cholecy− stectomy was performed and a T tube left in place. The postoperative course was normal. It would appear that air in− flation during the esophagogastroduode− noscopy had facilitated the passage of air from the duodenum to the peritoneum across the fistula created by the percuta− neous drain; the ascitic liquid, leaving a distance between the hepatic surface and the abdominal wall, made develop− ment of the pneumoperitoneum even ea− sier, because of the incomplete consolida− tion of the biliocutaneous fistula. In patients with a biliocutaneous fistula after percutaneous drainage, early endo− scopic examination with insufflation of air can facilitate free passage of air into the abdomen from the fistula. Ascites may facilitate this process further; if as− cites is present, therefore, it may be use− ful to leave in place an external biliary drain after placement of the stent to al− low the fistula to consolidate. Definitive removal of the external drain may be more safely carried out 3 ±5 days after the endoscopic procedure. Endoscopy_UCTN_Code_CPL_1AK_2AD Endoscopy_UCTN_Code_CPL_1AK_2AH