Fig. 11

An elderly 80-year-old male with multiple comorbidities underwent endoscopic treatment of choledocholithiasis, including pre-cut sphincterotomy of the Vaterian papilla and stone retrieval using a basket device. During ERCP, fluoroscopy (a) showed opacification of dilated intrahepatic and common bile ducts and of a sizeable extraluminal CM collection (thin arrows) from lateral duodenal wall perforation (type I according to the Stapfer classification system). A few hours later CT (b–d) showed diffuse gaseous bowel distension from insufflation during endoscopy, presence of posterior pneumomediastinum, perihepatic and right parietocolic pneumoperitoneum (*), and extensive retroperitoneal emphysema in the right perirenal, posterior and anterior pararenal spaces (+). Note persistently opacified intrahepatic and common bile ducts with residual lithiasis fragments (arrowheads), persistently extravasated CM (arrow in d). Imaging findings and worsening clinical conditions with peritonitis dictated urgent laparotomy, which confirmed intra-abdominal free air, and included opening and toilette of common bile duct and positioning of a Kehr T-tube. The patient finally recovered after a prolonged hospital stay