Air Everywhere: A Rare Post-ERCP Syndrome of Acute Pancreatitis, Pneumothorax, and Multicompartment Air Leak without Perforation.

Endoscopic retrograde cholangiopancreatography (ERCP) is a widely used therapeutic procedure for pancreatobiliary disorders but is associated with a range of complications, most commonly post-ERCP pancreatitis (PEP). Post-ERCP air leak syndromes-including pneumothorax, pneumomediastinum, pneumoperitoneum, and subcutaneous emphysema-are exceptionally rare, particularly in the absence of an identifiable gastrointestinal perforation. We report the case of a 72-year-old woman who developed severe abdominal pain, acute respiratory distress, and hypoxemia 6 hours after ERCP performed for common bile duct stenting and biopsy of a suspected biliary tumor. Laboratory investigations revealed markedly elevated serum amylase and lipase, consistent with acute pancreatitis. Imaging demonstrated a moderate right-sided pneumothorax, diffuse pneumomediastinum, pneumoperitoneum, pneumoretroperitoneum, extensive subcutaneous emphysema, and radiological features of acute pancreatitis, without evidence of duodenal or esophageal perforation. The patient was managed conservatively in the intensive care unit with bowel rest, intravenous fluids, antibiotics, supplemental oxygen, and close monitoring. Clinical and biochemical parameters improved progressively, with repeat imaging showing regression of air collections. This case highlights a rare constellation of post-ERCP complications occurring simultaneously without demonstrable perforation and underscores the importance of prompt recognition, multidisciplinary assessment, and individualized conservative management in selected stable patients.