Portal vein filling: an unusual complication of needle-knife sphincterotomy.

ciated with endoscopic retrograde cho− langiopancreatography (ERCP) are pan− creatitis, hemorrhage, and perforation. We report an unusual case of portal vein filling after needle−knife sphincterotomy in a patient with a pancreatic carcinoma. A 59−year−old woman was admitted to our hospital with obstructive jaundice, fever, elevated liver enzymes, and dilata− tion of the biliary and pancreatic ducts. Magnetic resonance imaging revealed a mass at the head of the pancreas. An ERCP with needle−knife sphincterotomy was performed over a pancreatic stent after several failed cannulation attempts. On cannulation, contrast was noted to clear within a few seconds (l" Figure 1). Aspiration revealed blood, indicating pos− sible cannulation of the portal vein, and the procedure was terminated immedi− ately. The patient went into atrial fibrilla− tion in the recovery room, but this re− versed spontaneously within 6 hours. The patient was operated on 3 weeks lat− er. She was found to have an adenocarci− noma of the pancreas with no signs of portal vein infiltration, and a cephalic duodenopancreatectomy was performed. Histological examination of the resected specimen identified an infiltrating ductal adenocarcinoma, stage T3N0M0, with in− filtration of the superior mesenteric vein. The patient subsequently received che− motherapy and radiation therapy and has remained stable over the 6 months since her operation. Filling of the portal venous system is an infrequent complication of ERCP, with an incidence between 1 in 6000 and 1 in 8000 cases [1,2]. Most of these patients presented with adenocarcinoma of the pancreas. It has also been described with different cannulation techniques [3, 4]. This complication can result from lacera− tion of a small portal vein [2 ± 4] or from direct trauma to the papilla [5]. Neo−an− giogenesis or aberrant vessels resulting from the cancer can also explain its occur− rence, as reported in the literature. Filling of the portal vein at ERCP carries potential risks, including bleeding, sepsis, thrombosis, and air embolism. Aspiration of the duct before the injection of con− trast might aid in its prompt diagnosis.