Duodenal perforation secondary to migration of endobiliary prosthesis

A 27-year-old woman presented to the emergency department with abdominal pain, four days post endoscopic retrograde cholangiopancreatography (ERCP) and insertion of an endobiliary stent. A plain abdominal film highlighted the stent in an atypical position within the abdomen. As such, the patient progressed to a CT scan, confirming a retroperitoneal perforation of the duodenum by the stent. Laparotomy returned the stent to the duodenum with a primary duodenal repair. This case highlights the high index of suspicion required in patients who present with acute abdominal pain post-ERCP.