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Early removal of a percutaneous transhepatic biliary drainage (PTBD) tube commonly causes pneumoperitoneum. However, weencountered a patient who developed pneumoperitoneum even with an indwelling PTBD tube. An 84-year-old man was admittedwith type III combined duodenal and biliary obstruction secondary to metastatic bladder cancer. A biliary stent was placed using apercutaneous approach, and a duodenal stent was placed endoscopically. A large amount of subphrenic free air was detected afterthe procedures. Laboratory tests indicated intestinal perforation; however, peritoneal signs were absent. The patient was treatedconservatively using an indwelling Levin tube. Seven days later, the massive amount of subphrenic free air disappeared. Follow-uptubography revealed unrestricted bile flow into the small intestine, and the PTBD tube was removed. Prolonged endoscopic proceduresin patients with a PTBD tract communicating with the gastrointestinal tract can precipitate pneumoperitoneum. Clinicians should becareful to avoid misdiagnosing this condition as intestinal perforation.
