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Complication of Waldenströem’s macroglobulinaemia following ERCP
  1. M Pascu,
  2. B Hanke,
  3. B Wiedenmann,
  4. F Martens,
  5. A U Dignass
  1. Department of Medicine, Division of Hepatology and Gastroenterology and Division of Nephrology and Internal Intensive Care, Charité Medical School, Virchow Hospital, Berlin, Germany
  1. Correspondence to:
    Dr M E Pascu
    Charité Medical School-Virchow Clinic, Department of Medicine, Division of Hepatology and Gastroenterology, Augustenburger Platz 1, D-13353 Berlin, Germany;

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Clinical presentation

A 74 year old woman with symptomatic common bile duct dilatation and gastric outlet obstruction because of Waldenströem’s macroglobulinaemia (WM) with nodal and duodenal involvement, underwent endoscopic retrograde cholangiography (ERC) to decompress the bile duct before initiating chemotherapy. Because of difficulties in cannulating the papilla, a pre-cut sphincterotomy was performed. Shortly after the intervention the patient developed acute haemodynamic and respiratory failure and subsequently acidosis, with a serum lactate of 72 mg/dl. Her abdomen was extremely tense and tympanic, and venous congestion and cyanosis of the abdomen and lower limbs were observed. Extensive subcutaneous emphysema developed within minutes extending from the abdomen to the chest walls. A left lateral decubitus abdominal radiograph was performed and is shown below (fig 1).

Figure 1

 Abdominal radiograph.


What does this image (fig 1) show and does it help to explain the clinical course?

See page 1812 for answer

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