Air Embolism after Endoscopic Retrograde Cholangiopancreatography in a Patient with Budd Chiari Syndrome

Abstract

Endoscopic retrograde cholangiopancreatography is a procedure commonly used for the diagnosis and treatment of various pancreatic and biliary diseases. Air embolism is a rare complication, which may be associated with this procedure. This condition can be manifested as cardiopulmonary instability and/or neurological symptoms. Known risk factors include: sphincterotomy; application of air with high intramural pressure; anatomic abnormalities; and chronic hepatobiliary inflammation. It is important for the health-care staff, including anesthesiologists, interventional gastroenterologists, and critical care specialists, amongst others, to promptly recognize air embolism and to initiate therapy in a timely fashion, thus preventing potentially fatal outcomes. We submit a brief review of the literature and a case report of air embolism which occurred in the immediate postoperative stage of an endoscopic retrograde cholangiopancreatography, performed in a woman with a history of liver transplantation due to Budd Chiari syndrome and biliary stricture.

A Dreaded Procedural Complication During Endoscopic Retrograde Cholangiopancreatography

“…Rapid egress of air that enters the systemic circulation led to the strain on the right ventricle. This, in turn, leads to cardiovascular compromise that, unfortunately, does not respond to resuscitative maneuvers [4].…”

“…Following cardiopulmonary resuscitation, the return of spontaneous circulation was obtained and put on a ventilator and inotropic supports. Later, the patient was recovered [4]. Hauser et al described another case of sudden death following ERCP in a patient of non-Hodgkin lymphoma with cholestatic jaundice due to gall stones [10].…”

Uncommon Occurrences of Air Embolism: Description of Cases and Review of the Literature

“…The severe neurologic symptoms and their abrupt onset must be ascribed either to the concurrent presence of a retrograde VGE in the right IJV, and/or to air bubbles escaping into the systemic circulation through a intrapulmonary shunt or the transcapillary route that determined a massive ischemic injury in the territory of the right middle cerebral artery [ 30 , 32 , 33 ]. The diagnosis of cerebral GE was particularly difficult due to a number of circumstances, including the sedation, the lack of preliminary symptoms, and, most importantly, the extremely uncommon occurrence of this complication [ 29 , 34 , 35 ]. Despite the aggressive and multimodal treatment of this patient, which included also a decompressive craniotomy besides HBOT, the ischemic damage was so relevant that the neurologic conditions failed to improve in the following months.…”

Gas embolism during endoscopic retrograde cholangiopancreatography: diagnosis and managementn

“…Chest x-ray findings include air in pulmonary artery, characteristic of pulmonary venous air embolism, pulmonary edema, adult respiratory distress syndrome, diminished vascularity in the upper lobes (air emboli common in upper lobes), intracardiac air, and atelectasis [47,48]. Computed tomography (CT) of the chest shows air in the pulmonary artery, heart and right ventricle [31,49,50]. CT of the abdomen can show air in the portal vein if the portal vein is cannulated (Fig.…”