Emphysematous cholangitis with pneumoperitoneum at ERCP

A 78-year-old woman with hilar cholangiocarcinoma and pre-existing plastic biliary stents presented with septic shock secondary to cholangitis. Abdominal CT revealed a large, subcapsular, air-filled cavity in the right hepatic lobe extending from the tip of the right hepatic stent, with only a thin rim of capsule at the superior aspect (A, arrows). After resuscitation with fluids, antibiotics, and vasopressors, emergent ERCP was performed. On...