Introduction:

Endoscopic retrograde cholangiopancreatography (ERCP) is a fundamental therapeutic procedure in biliopancreatic disease, although it is associated with potentially severe complications, including post-ERCP pancreatitis (PEP) and duodenal perforation. The latter is rare but carries a high mortality rate.

Case Presentation:

A 52-year-old previously healthy woman underwent ERCP for obstructive choledocholithiasis. Within the first 24 hours, she developed abdominal pain, distension, vomiting, and hemodynamic instability, with elevated serum amylase levels initially consistent with PEP. Due to clinical deterioration, contrast-enhanced computed tomography revealed pneumoretroperitoneum and extensive free fluid, findings suggestive of duodenal perforation. Emergency laparotomy confirmed a perforation in the second portion of the duodenum, which was managed with primary repair and abdominal lavage. The postoperative course was complicated, requiring reinterventions, open abdomen management, and intensive care support.

Discussion:

The coexistence of PEP and duodenal perforation is exceptional and significantly complicates early diagnosis due to overlapping clinical manifestations. Early computed tomography and timely surgical decision-making were decisive in management.

Conclusion:

This case highlights the need for high clinical suspicion and early imaging evaluation in patients with atypical post-ERCP evolution, as well as the importance of a staged, multidisciplinary management approach in highly complex clinical scenarios.

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