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A 55-year-old female heavy smoker was admitted electively for therapeutic endoscopic retrograde cholangio-pancreatography (ERCP). Two weeks previously she had presented with right upper quadrant discomfort and cholestatic liver function tests. Magnetic resonance cholangio-pancreatography (MRCP) revealed a dilated common bile duct with intra-ductal filling defects.
Post-ERCP the patient was notably short of breath, complained of a left-sided pleuritic chest pain, and her oxygen saturation had fallen from 98% to 90% while breathing ambient air.
A chest radiograph (fig 1) revealed loss of lung volume on the left side with a straight heart border and obscuration of the left hemi-diaphragm—consistent with left lower lobe collapse. Computed tomography of the chest with intravenous contrast material (fig 2) revealed complete left lower lobe collapse with an radiopaque object within the left lower main bronchus surrounded by a halo of air.
To our surprise bronchoscopy retrieved a 750 mg ciprofloxacin tablet given as a prophylactic antibiotic 1 h before the procedure. On re-questioning the patient remembered choking on the tablet, as she had found it difficult to swallow the large tablet with only a sip of water and a dry mouth (having been “nil-by-mouth” since midnight).
Just as it seems that, with preoperative/procedure fasting, longer is not necessarily better, perhaps we should increase the amount of water given with medications from the traditional sips to up to the 150 ml 1 h before anaesthesia, as allowed by recent guidelines.1 Nevertheless, a review of the literature did not reveal a prior documented case in the context of an ERCP.
Competing interests: none.
Patient consent: Patient/guardian consent was obtained for publication