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the first endoscopic pancreatogram was obtained in 1968 , and in 1974 , biliary sphincterotomy was first described .
this was followed by the first report of papillotomy for the management of choledocholithiasis , and in subsequent years numerous endoscopic techniques evolved to address pancreaticobiliary disease .
as computerized axial tomography and magnetic resonance imaging have improved , endoscopic retrograde cholangiopancreatography ( ercp ) has evolved from primarily a diagnostic procedure into primarily a therapeutic procedure . as the indications for ercp have increased , a greater focus on recognizing and preventing complications
indeed , ercp is a well - established effective procedure for the diagnosis and treatment of biliary and pancreatic diseases , however , various complications including pancreatitis , duodenal or common bile duct ( cbd ) perforation , hemorrhage , infection , and general cardiac and pulmonary complications still may occur .
it was reported that , in the 16,855 patients evaluated , ercp - specific morbidity totaled 1,154 ( 6.85% ) .
ercp - related perforation is one of the most serious complications and its incidence was reported from 0.12 to 0.60% [ 4 , 5 , 6 ] .
it is generally agreed that some ercp - related perforations can be successfully managed without surgery , however , it is difficult to define these patients .
ercp - related perforation is classified into guide wire perforation of the bile duct or pancreatic duct , periampullary perforation related to sphincterotomy , and duodenal perforation remote from the papilla .
guide wire perforation is usually recognized in the bile duct or pancreatic duct , and penetration of the liver parenchyma is rare .
we herein report on the case of a female patient who developed liver parenchyma perforation due to guide wire following ercp .
we report on the case of a 77-year - old japanese woman who presented with right upper quadrant abdominal pain , nausea , and slight jaundice .
her serum levels of total bilirubin and alkaline phosphatase were high , up to 3.7 mg / dl ( normal range 0.3 - 1.2 mg / dl ) and 513 iu / l ( normal range 115 - 359
she underwent ercp with sphincterotomy and extraction of the cbd stone for the diagnosis of choledocholithiasis .
shortly after ercp , abdominal distension , hypotension , tachycardia , and tachypnea were identified .
she underwent emergency abdominal ct , which revealed intraabdominal air leakage and leakage of contrast medium penetrating the liver parenchyma into the space around the spleen ( fig .
ercp imaging showed deep cannulation of the guide wire into the left intrahepatic bile duct , retrospectively ( fig .
2 ) . liver parenchyma perforation due to the guide wire was most likely , however , periampullary perforation related to sphincterotomy could not be denied .
, there was no bile leakage , and neither obvious liver parenchyma perforation nor periampullary perforation was found .
however , periampullary perforation is often difficult to identify in the operating room . therefore , cholecystectomy , insertion of a t tube into the cbd , and placement of a duodenostomy tube were performed to divert bile and succus entericus away from the duodenal ampulla . finally
the duodenostomy tube and the t tube were removed on pod 18 and pod 25 , respectively .
some authors have advocated immediate surgery for all endoscopic shincterotomy perforations , but others have reported that most perforations may be managed without surgery .
wu et al .   summarized as follows : guide wire perforation is benign in nature and can be treated with medical therapy .
periampullary perforation is associated with a high morbidity and mortality and should have aggressive surgery .
, there should be a high index of suspicious for perforation in any patient with significant abdominal pain following therapeutic ercp , and an early ct scan should be considered in these patients .
. guide wire perforation is usually recognized in the bile duct or pancreatic duct by extravasation of contrast dye on fluoroscopy during ercp , and penetration of the liver parenchyma is rare .
the present case is a rare case of a patient who developed liver parenchyma perforation due to guide wire following ercp .
although immediate surgery was performed about 5 h after ercp , obvious liver parenchyma perforation could unfortunately not be found .
it is possible that the perforation site had been very tiny and had healed naturally at surgery . in the present case
, we performed cholecystectomy , insertion of a t tube into the cbd , and placement of a duodenostomy tube .
the reason was that periampullary perforation related to sphincterotomy still could not be denied during the operation .
periampullary perforation is often difficult to identify in the operating room , and a delay in treatment will lead to death . therefore ,
an aggressive surgery to divert bile and succus entericus away from the perforation site should be performed . in conclusion , as it is well recognized that perforation is one of the most serious complications related to ercp , liver parenchyma perforation due to guide wire should be suspected as a cause .
although endoscopic retrograde cholangiopancreatography ( ercp ) is an effective modality for the diagnosis and treatment of biliary and pancreatic diseases , it is still related with several severe complications . 
 we report on the case of a female patient who developed liver parenchyma perforation following ercp . 
 she underwent ercp with sphincterotomy and extraction of a common bile duct stone . 
 shortly after ercp , abdominal distension was identified . 
 abdominal computed tomography revealed intraabdominal air leakage and leakage of contrast dye penetrating the liver parenchyma into the space around the spleen . 
 since periampullary perforation related to sphincterotomy could not be denied , she was referred for immediate surgery . 
 obvious perforation could not be found at surgery . 
 cholecystectomy , insertion of a t tube into the common bile duct , placement of a duodenostomy tube and drainage of the retroperitoneum were performed . 
 she did well postoperatively and was discharged home on postoperative day 28 . in conclusion , as it is well recognized that perforation is one of the most serious complication related to ercp , liver parenchyma perforation should be suspected as a cause .