A53-14 Fatal Subcutaneous Emphysema Following ERCP

Abstract Introduction Subcutaneous emphysema is one of the more common complications of laparoscopic surgical procedures, with an incidence of approximately 0.43%-2.34%. Subcutaneous emphysema occurring after endoscopic retrograde cholangiopancreatography (ERCP) is a rare but recognized complication, most commonly occurring secondary to visceral organ perforation. We present a case of diffuse subcutaneous emphysema, pneumomediastinum, and pneumoperitoneum leading to multiorgan failure after ERCP. Case Presentation A 67-year-old male with a history of hypertension, compensated liver cirrhosis, and heart failure with reduced ejection fraction presented with acute abdominal pain. His initial workup revealed choledocholithiasis and cholelithiasis. He underwent an MRCP to confirm the diagnosis, and an ERCP was attempted but was aborted due to difficulty cannulating the peridiverticular papilla.Postoperatively, the patient developed diffuse subcutaneous emphysema extending from the head to the bilateral lower extremities. CT scan of the chest, abdomen, and pelvis revealed extensive subcutaneous emphysema, pneumomediastinum, pneumopericardium, pneumothoraces, and pneumoperitoneum. Given concern for esophageal rupture or gastrointestinal perforation, he was evaluated by cardiothoracic surgery and gastrointestinal teams. However, multidisciplinary discussions suggested that the complication was more likely related to an intestinal perforation. He became progressively more hypoxemic and hypotensive requiring continued mechanical ventilation and vasopressor support. The patient was too hemodynamically unstable to undergo a surgical intervention. Blowholes were performed to release the extensive subcutaneous emphysema. His condition continued to deteriorate, prompting the family to transition the patient to comfort care. Discussion It is estimated that approximately 500,000 ERCPs are performed annually in the United States, with complications occurring in 6-10% of cases. Organ perforation during ERCP is rare, occurring in less than 1% of cases. However, when perforation does occur, the mortality rate increases significantly, ranging from 16% to 18%. Patients at increased risk for perforation during ERCP include those with malignancy, advanced age (greater than 80 years), and those undergoing sphincterotomy in the pancreatic duct. An additional risk factor is the presence of anatomical abnormalities in the surrounding structures, such as diverticula, which are present in about 65% of Western population. Although diverticula are common, they can precipitate rare but severe complications, such as subcutaneous emphysema secondary to perforation. Although subcutaneous emphysema is a relatively uncommon and often overlooked finding in clinical practice due to its typically benign nature, it can, in rare cases, be fatal. This case underscores the importance of recognizing and communicating to patients that common, everyday procedures still carry risks and the importance of identifying potential risk factors for complications. This abstract is funded by: None