neum, and subcutaneous emphysema complicating ERCP with sphincterotomy is reported. A 56−year−old woman with acute cholan− gitis underwent ERCP with sphinctero− tomy and extraction of the choledochal

giopancreatography (ERCP) and sphinc− terotomy is an essential diagnostic and therapeutic modality for biliary and pan− creatic diseases, it carries significant mor− bidity. A rare case of bilateral pneumo− thorax along with pneumomediastinum, pneumoperitoneum, pneumoretroperito− neum, and subcutaneous emphysema complicating ERCP with sphincterotomy is reported. A 56−year−old woman with acute cholan− gitis underwent ERCP with sphinctero− tomy and extraction of the choledochal duct stones. Over the ensuing 20 min, hy− potension, tachycardia, tachypnea, de− creased oxygen saturation, bilaterally di− minished breath sounds, abdominal dis− tension, and subcutaneous emphysema were identified. Chest and abdominal radiography revealed bilateral pneumo− thorax, pneumomediastinum, subcuta− neous emphysema, pneumoperitoneum, and pneumoretroperitoneum (l" Figure 1 and l" 2). The patient was managed with immediate bilateral chest tube place− ment, nasogastric suction, and broad− spectrum antibiotics, and was discharged on the tenth day. Pneumothorax, pneumomediastinum, pneumoperitoneum, subcutaneous em− physema, and pneumoretroperitoneum after ERCP are rare [1± 5]. Bilateral pneu− mothorax has only once been reported [4]. The most usual origin of air leakage is from a duodenal perforation [5]. However, in the absence of obvious perforation, air dis− section is probably related to the use of compressed air to maintain patency of a lumen [5]. Since no perforation was iden− tified in our patient in the postsphincter− otomy cholangiogram, esophagogram, upper gastrointestinal series, and abdom− inal CT, we postulate that the complication presented here occurred due to interstitial air tracking from the duodenum because of increased airway pressure after air in− sufflation during ERCP. However, the pos− sibility of a small perforation that could not be demonstrated may be taken into consideration. Air can dissect from the ret− roperitoneum into the peritoneum, me− diastinum, pleura, or subcutaneous tissue, resulting in pneumoperitoneum, pneu− momediastinum, pneumothorax, or sub− cutaneous emphysema, respectively [1]. Subcutaneous emphysema, pneumotho− rax, pneumomediastinum, pneumoperi− toneum, and pneumoretroperitoneum constitute infrequent complications of ERCP/endoscopic sphincterotomy while bilateral pneumothorax is extremely rare. Despite the dramatic physical and radiographic findings, the patient respon− ded to early treatment and conservative management with a favorable outcome.