Endoscopic Retrograde Cholangiopancreatography (ERCP)-Related Duodenal Perforation: Management Challenges and Lessons From a Case Series.

Duodenal perforation is a rare but harmful complication of endoscopic retrograde cholangiopancreatography (ERCP). Early diagnosis and appropriate management are critical to reduce morbidity and mortality. Four patients, aged 36 to 56 years, underwent ERCP for biliary obstruction due to choledocholithiasis or postoperative biliary stricture. Symptom onset ranged from 12 to 40 hours post-ERCP. Imaging revealed retroperitoneal air, periduodenal fluid collections, or free intraperitoneal air. Three patients were initially managed conservatively. Two of them subsequently required delayed surgical intervention due to clinical deterioration. One patient was treated non-operatively throughout the hospital stay but did not recover; the family declined surgery. Another patient underwent early operative management based on overt signs of generalized peritonitis and pneumoperitoneum. Duodenal perforation was classified as Stapfer type II in three cases and type I in one case. This case series highlights the clinical variability and diagnostic challenges associated with ERCP-related duodenal perforations. Accurate classification using the Stapfer system and timely diagnosis with contrast-enhanced CT are crucial in guiding management. While conservative treatment may be effective in selected patients, delayed recognition or clinical deterioration often necessitates surgical intervention. Concomitant complications, such as acute pancreatitis, necrotizing cholecystitis, liver cirrhosis, or ampullary bleeding, can affect the clinical picture of perforation and worsen the overall prognosis. Aggressive drainage and enteral feeding via jejunostomy contributed positively to local control of pancreatic inflammation and promoted duodenal healing. Prompt diagnosis and multidisciplinary approach strategies are key to optimizing outcomes in ERCP-related duodenal perforations.