Archives of Academic Emergency Medicine. 2022; 10(1): e21 CA S E RE P O RT Right Upper Quadrant Pain Following Endoscopic Retro- grade Cholangiopancreatography; a Case Report Lan Thi Nguyen1∗, Dang Hai Do2, An Duc Thai2, Hoa Thi Nguyen3 1. Department of Hepatobiliary Surgery, VietDuc University Hospital, Hanoi, Viet Nam. 2. Department of General Surgery, Hanoi Medical University, Hanoi, Viet Nam. 3. Center of Anesthesia and Surgical Intensive Care, VietDuc University Hospital, Hanoi, Viet Nam. Received: January 2022; Accepted: February 2022; Published online: 16 March 2022 Abstract: Endoscopic retrograde cholangiopancreatography (ERCP) is a standard for diagnosing and treating hepato- pancreatico-biliary (HPB) diseases in clinical settings. ERCP-related complications are relatively common, rang- ing from 4 to 30%. The most common one is acute pancreatitis. ERCP-related necrotizing pancreatitis accounts for 7.7% of ERCP-related pancreatitis cases. This complication may still be misdiagnosed, which might lead to inappropriate treatment with a worse prognosis. Here, we report a 34-year-old case with ERCP-related necrotiz- ing pancreatitis who was successfully managed, but initially misdiagnosed with biliary peritonitis. Keywords: Pancreatitis, acute necrotizing; peritonitis; cholangiopancreatography, endoscopic retrograde; case reports Cite this article as: Nguyen LT, Do DH, Thai AD, Nguyen HT. Right Upper Quadrant Pain Following Endoscopic Retrograde Cholangiopan- creatography; a Case Report. Arch Acad Emerg Med. 2022; 10(1): e21. https://doi.org/10.22037/aaem.v10i1.1535. 1. Introduction Endoscopic retrograde cholangiopancreatography (ERCP) is a common tool for diagnosing and treating hepato- pancreatico-biliary diseases. Via direct vision of the bile duct, sphincterotomy and gallstone removal are conducted, and it has truly become the standard treatment for common bile duct (CBD) stone removal nowadays. ERCP-related compli- cations are relatively common, ranging from 4 to 30% [1]. Most of these complications are not too serious and can be conservatively treated; however, the challenges lie in critical cases. The mortality rate was reported to be 0.5-1.5% and as high as 18% in duodenal injury (2, 3). Pancreatitis, bleeding, perforation, and cholangitis are the most common complications. Though the methods for diag- nosis and treatment have been established, in some sophis- ticated cases, a misdiagnosis could still occur, which might lead to inappropriate treatment with a worse prognosis. We report successful surgical management for a 34-year-old case with ERCP-related necrotizing pancreatitis, which was first misdiagnosed as biliary peritonitis. ∗Corresponding Author: Lan Thi Nguyen; Department of Hepatobiliary surgery VietDuc University Hospital, 40 Trang Thi street, Hoan Kiem, Hanoi, 100000, Viet Nam. Tel: +84983289213, Email: dr.nguyenlanvd@gmail.com, OR- CID: https://orcid.org/0000-0002-9735-0175. 2. Case presentation A 34-year-old woman came to the emergency department with the symptoms of right upper quadrant pain and a mild fever for the past two weeks. Her husband reported a his- tory of choledocholithiasis six months ago without any inter- vention. Three days before hospitalization, the patient un- derwent sphincterotomy and stone removal via ERCP in a regional hospital. The next day, she had intense pain and a high temperature (39°C). A computed tomography (CT) scan was conducted, which showed a sign of intra-abdominal free fluid, air, and fat stranding around the descending part of the duodenum; pancreatic parenchyma was normal, and there was no sign of infection. Suspected of having an ERCP- related perforation, ERCP was conducted again, and a plas- tic stent was inserted in the biliary duct. Simultaneously, ab- dominal drainage was also placed. However, her condition did not improve, and she was transferred to our hospital. The patient was admitted to our hospital in an unstable state, with tachycardia and 38.5°C fever. The examination showed abdominal distension and right-sided abdominal re- bound tenderness and ascitic fluid was spotted. Her blood test showed a high white blood cell count 13.2 G/l (98.7% Neutrophil), calcium 1.43 mmol/l, elevated alanine amino- transferase and aspartate aminotransferase levels (69 and 225.1 U/l, respectively), and total bilirubin 13 umol/l, amy- lase 349.9 U/L, and lipase 338.5 U/L. Bedside Index for Sever- This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: http://journals.sbmu.ac.ir/aaem LT. Nguyen and et al. 2 Figure 1: Coronal (left) and axial (right) views of abdominal Magnetic resonance imaging (MRI) at the time of admission. Figure 2: The operative findings of the reported case. The non-perforated common bile duct (left) and peripancreatic fat necrosis caused by necrotizing pancreatitis (right). ity in Acute Pancreatitis (BISAP) score was 3 points, CT Sever- ity Index (CTSI) score was 0 points. The magnetic resonance imaging (MRI) scan also suggested common bile duct perfo- ration, with no clear sign of edematous or necrotizing pan- creatitis (figure 1). An emergency operation was conducted 8 hours after admission. Unexpectedly, the cause was not an ERCP-related perforation (figure 2). Intraoperative findings revealed peripancreatic fat necrosis throughout the abdomen, severe inflammation in the head of the pancreas, and small residual common bile duct (CBD) stones (figure 2). She underwent CBD clearance and stone removal with T-tube drainage, cholecystectomy, and Witzel jejunostomy for feeding. Four drainage tubes were placed in the transhepatic, peripancreatic, and Dough- las regions. The calculated Imrie score and Acute Physiol- ogy and Chronic Health Evaluation (APACHE) II scores were 2 and 9 points, respectively, which means the patient was un- der severe conditions with the risk of mortality of 11-18%. She was immediately admitted to the intensive care unit and was managed critically with analgesia, antibiotics, somato- statin, and proton pump inhibitors for 10 days. Parenteral nutrition was applied and gradually turned into enteral nu- trition via Witzel jejunostomy. Fortunately, the symptoms were relieved, and she was discharged 1 month later and was stable during the follow-up. 3. Discussion The number of ERCP procedures has been increasing in re- cent years, and ERCP is becoming a practical tool for clini- cians in diagnosing and treating HPB diseases (4, 5). Though the risk of complications is as low as 4%, severe complica- tions are truly a matter of concern. 10-20% of them are clas- sified as “severe” with an overall mortality rate of 1-1.5% (6, 7). The most common complications include severe pancre- atitis, perforation, and hemorrhagic shock. The overall risk increases in patients with sphincter of Oddi dysfunction and sphincterotomy, while severe complications are associated with systemic disease, obesity, prolonged procedures(6). ERCP-related necrotizing pancreatitis is a rare condition, ac- counting for 7.7% of ERCP-related pancreatitis (8). In a study by Fung on 72 patients with necrotizing pancreatitis, 6 of the cases (8.3%) were caused by ERCP, and they also had a This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: http://journals.sbmu.ac.ir/aaem 3 Archives of Academic Emergency Medicine. 2022; 10(1): e21 higher APACHE score (9). Potential mechanisms may origi- nate from mechanical, chemical, thermal, hydrostatic, bio- chemical factors. More specifically, papillary edema and spasms cause pancreatic fluid obstruction and pancreatitis. Besides, activated pancreatic enzymes may damage and “au- todigest” the parenchyma, while other factors such as injec- tion pressure, iatrogenic, contrast media, and thermal injury may facilitate the process (10). A retrospective study by Vege showed that 7.7% of severe acute pancreatitis cases were caused by ERCP, with a mortal- ity rate of 25%, slightly higher than other causes [8]. We also thought that a prognostic model should be adopted. How- ever, since the patient had high APACHE II and Systemic in- flammatory response syndrome (SIRS)24-48 scores but low SIRS0-24 score diagnosing her problem was really challeng- ing (8, 11). At first, we misdiagnosed the patient with ERCP-related bile duct perforation. Examination showed right-sided rebound abdominal tenderness while the previous ERCP showed thickened, inflamed papilla. MRI also suggested a 3 mm per- forated site in the lower part of the common bile duct, free fluid with no air in the peripancreatic and retroperitoneal re- gion. Emergency operation was chosen as previous evidence showed their benefits for patients with unstable conditions (12, 13). The symptoms were then determined to be caused by pancreatic necrosis and no sign of perforation was spot- ted. Interestingly, a research by Fathi on 2447 patients, with 6.9% complications, also showed that rebound tenderness did not occur in pancreatitis, but is suggestive of perfora- tion (7). While the two conditions had different approaches, we thought that severe pancreatitis should not be excluded when peritonitis is present and prophylaxis for high-risk pa- tients should be further studied. In this case, ERCP and MRI could not be a gold standard since the papilla was inflamed. If a patient’s conditions do not improve, the doctor should promptly head to another morbidity. And finally, Witzel je- junostomy should be applied since it modulates the inflam- matory response and reduces the rate of organ failure better than parenteral nutrition. 4. Conclusion ERCP-related necrotizing pancreatitis is a truly hazardous condition and might be misdiagnosed with other causes of peritonitis. A comprehensive study should be conducted, and larger studies are needed to find the best approach for its management. 5. Declarations 5.1. Acknowledgments We would like to express our thanks to all the medical staff in Department of Hepatobiliary surgery, Center of Anesthe- sia and Surgical intensive care, Medical Imaging and Nu- clear Medicine Center ,for their contribution to diagnosis and management of the patient. 5.2. Author contribution Lan NT: Main surgeon, wrote manuscript, did the man- agement strategy Dang DH: Assistant surgeon, wrote manuscript, did the management strategy An NT: Assistant surgeon, wrote manuscript Hoa NT: Did the anesthesia, data collection 5.3. Source of Support and Funding None. 5.4. Conflict of Interest None. 5.5. Data Availability Authors guarantee that data of the study is available and will be provided to anyone needing it. 5.6. Ethical issues Written informed consent was obtained from the patient for publication of this case report and accompanying images. No identity will be published, and all the published information will be used for education purposes only. The patient under- stands that name and initials will not be published, and due efforts will be made to conceal identity, but anonymity can- not be guaranteed. The study was approved by our institu- tional research committee. References 1. Freeman, M.L., Adverse outcomes of ERCP. Gastrointest Endosc, 2002. 56(6 Suppl): p. S273-82. 2. Stapfer, M., et al., Management of duodenal perforation after endoscopic retrograde cholangiopancreatography and sphincterotomy. Ann Surg, 2000. 232(2): p. 191-8. 3. Cotton, P.B., et al., Endoscopic sphincterotomy compli- cations and their management: an attempt at consensus. Gastrointest Endosc, 1991. 37(3): p. 383-93. 4. Kroner, P.T., et al., Use of ERCP in the United States over the past decade. Endosc Int Open, 2020. 8(6): p. 761-769. 5. Park, J.M., et al., Recent 5-Year Trend of Endoscopic Ret- rograde Cholangiography in Korea Using National Health Insurance Review and Assessment Service Open Data. Gut Liver, 2020. 14(6): p. 833-841. This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: http://journals.sbmu.ac.ir/aaem LT. Nguyen and et al. 4 6. Cotton, P.B., et al., Risk factors for complications after ERCP: a multivariate analysis of 11,497 procedures over 12 years. Gastrointest Endosc, 2009. 70(1): p. 80-8. 7. Fathi, A., F. Lahmi, and R. Kozegaran, Surgical manage- ment of ERCP-related complications. Gastroenterol Hep- atol Bed Bench, 2011. 4(3): p. 133-7. 8. Vege, S.S., et al., Endoscopic retrograde cholangiopancreatography-induced severe acute pan- creatitis. Pancreatology, 2006. 6(6): p. 527-30. 9. Fung, A.S., G.G. Tsiotos, and M.G. Sarr, ERCP-induced acute necrotizing pancreatitis: is it a more severe dis- ease? Pancreas, 1997. 15(3): p. 217-21. 10. Sherman, S. and G.A. Lehman, ERCP- and endoscopic sphincterotomy-induced pancreatitis. Pancreas, 1991. 6(3): p. 350-67. 11. Sinha, A., et al., Systemic inflammatory response syn- drome between 24 and 48 h after ERCP predicts pro- longed length of stay in patients with post-ERCP pancre- atitis: a retrospective study. Pancreatology, 2015. 15(2): p. 105-10. 12. Alfieri, S., et al., Management of duodeno-pancreato- biliary perforations after ERCP: outcomes from an Italian tertiary referral center. Surgical Endoscopy, 2013. 27(6): p. 2005-2012. 13. Theopistos, V., et al., Non-Operative Management of Type 2 ERCP-Related Retroperitoneal Duodenal Perfora- tions: A 9-Year Experience From a Single Center. Gas- troenterology Res, 2018. 11(3): p. 207-212. This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: http://journals.sbmu.ac.ir/aaem Introduction Case presentation Discussion Conclusion Declarations References