Case report

Pancreatitis with an unusual fatal complication following endoscopic retrograde cholangiopancreaticography: a case report

Boris L Kanen and Ruud JLF Loffeld

Department of Internal Medicine, Zaans Medisch Centrum, Zaandam, The Netherlands

author email corresponding author email

Journal of Medical Case Reports 2008, 2:215doi:10.1186/1752-1947-2-215

Published:	24 June 2008

Abstract

Introduction

Endoscopic retrograde cholangiopancreaticography has been the treatment of choice for stones in the common bile duct. Although the procedure is usually safe, procedure-related complications do occur.

Case presentation

A case of pancreatitis following endoscopic retrograde cholangiopancreaticography is described in a 55-year-old woman. After an uneventful recovery the patient's condition deteriorated rapidly 16 days after the endoscopic retrograde cholangiopancreaticography, and the patient died within 1 hour. Post-mortem examination revealed massive intrapulmonary fat embolism. The complications of endoscopic retrograde cholangiopancreaticography and pancreatitis are described.

Conclusion

Fat embolism can occur after the remission of pancreatitis and pancreatic necrosis may be overlooked on contrast-enhanced computed tomography scanning.