Introduction: Endoscopic retrograde cholangiopancreatography (ERCP) is a diagnostic and therapeutic procedure for biliary and pancreatic diseases. It is associated with low rate of complications. However, some complications as duodenal perforation can be fatal. Presentation of cases: 852 patients underwent ERCP at our hospital, six patients had a duodenal perforation (0.7 %). All patients were admitted with clinical and biochemical findings of obstructive jaundice without acute cholangitis. All patients had biliary tree dilatation confirmed on abdominal ultrasound scan and/or magnetic resonance cholangiopanceatography. Two patients were initially managed surgically, one of them died due to multi-organ failure. The other four patients were initially treated conservatively; two of them failed conservative management with one death due to sepsis, other two patients recovered without complications. The overall mortality rate was (33.3 %). Discussion: Multiple attempts of CBD cannulation and pre-cut sphincterotomy may increase the possibility of duodenal perforation. In the presence of clinical suspicion of perforation, an early radiological imaging is helpful for an early intervention. Conclusion: A high index of suspicion is essential for early diagnosis and intervention to improve the clinical outcome. In difficult ERCP, performing a post-procedural fluoroscopy study with contrast injection is essential.
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