Gangrenous cholecystitis - a rare complication of ERCP

tive endoscopic retrograde cholangiopan− creatography (ERCP) following an episode of cholangitis. Abdominal ultrasound prior to ERCP showed contracted acalcu− lus gallbladder. ERCP revealed normal bile ducts (l" Figure 1). Sphincterotomy was performed. The procedure was un− eventful. The patient was admitted to the hospital 48 hours later due to increasing abdominal pain. Physical examination re− vealed right abdominal tendernesswith normal vital signs. Liver function tests were normal; white blood cell (WBC) count was 14 600/mm3. Computed to− mography (CT) scan demonstrated small air bubbles adjacent to the duodenum and a gallbladder filled with contrast ma− terial (l" Figure 2 a, b). Antibiotics were initiated due to suspect− ed duodenal microperforation. The pain had increased 24 hours later; tempera− ture was 39 8C, and WBC count was 20100/mm3. A repeat scan demonstrated an inflammatory process with air bubbles around the porta hepatisand a contrast− filled gallbladder. Emergency laparatomy revealed a necro− tic gallbladder with stones and no duode− nal perforation. A cholecystectomy was performed. Postoperative recovery was uneventful. Acute cholecystitisis a rare complication of ERCP [1± 4]. The mechanism is not clear. Cystic ductobstruction was sug− gested by the CT scan. A stone pushed by the contrast material might cause the ob− struction. However, in other reported cases [1 ± 3], emphysematous cholecysti− tis was attributed to gallbladder wall dis− tension and ischemia, due to the contrast material with no stones. In our case a combined mechanism probably led to gallbladder necrosis. Post−ERCP cholecys− titisis not necessarily instantaneous and may take 48 hours to develop. The con− siderationof other, more common post− ERCP complications causes delay in diag− nosis [1]. It is important to emphasize that retroperitoneal air bubbles around the duodenum is found in up to 30 % of asymptomatic patients following ERCP and sphincterotomy [5]. Acute cholecystitisshould be suspected in a septic patient following ERCP even when retroperitoneal air bubbles are demonstrated. A gallbladder filled with contrast material may be a clue for the di− agnosis. Urgent surgical intervention is recommended.