Fatal Biliary-Systemic Air Embolism during Endoscopic Retrograde Cholangiopancreatography: A Case with Multifocal Liver Abscesses and Choledochoduodenostomy

We report a rare case of a massive fatal embolism that occurred in the middle of endoscopic retrograde cholangiopancreatography (ERCP) and retrospectively examine the significant causes of the event. The patient was a 50-year old female with an uncertain history of previous abdominal surgery for multiple biliary stones 20 years prior. The patient presented with acute right upper quadrant pain. An abdominal computed tomographic (CT) scan revealed the presence of multiple stones in the common bile duct (CBD) and intra-hepatic duct (IHD) with biliary obstruction, multifocal liver abscesses, and air-biliarygram. Emergency ERCP showed a wide and straight opening of choledochoduodenostomy, which may have been created during a previous surgery, and multiple filling defects in the CBD. With the use of a forward endoscope, mud stones were extracted through the opening of the choledochoduodenostomy. Cardiac arrest suddenly developed during the procedure, and despite immediate resuscitation, the patient died due to a massive systemic air embolism. We reviewed previously reported fatal cases and accessed factors facilitating air embolisms in this case.

Neumatosis intestinal y gas portal, asociada a trombosis portal: comunicación de un caso y revisión de literatura / Pneumatosis intestinalis and portal hepatic gas in asociation with portal thrombosis

Se presenta un caso clínico de una asociación infrecuente de Neumatosis intestinal con gas en vena porta y trombosis portal. Mujer de 37 años quien presenta cuadro de distensión y dolor abdominal de cuadro días de evolución. A su ingreso se encuentra afebril con presión arterial de 120/70. A su examen físico destaca sólo sensibilidad abdominal. Se realiza tomografía computada de abdomen y pelvis que muestra presencia de imágenes quísticas con gas en pared de colon ascendente, aire en sistema venoso portal y trombosis en rama de la vena porta. Se inicia tratamiento con antibióticos y oxígeno.La paciente evoluciona en forma favorable siendo dada de alta 11 días después de su ingreso. Varios estudios han mostrado que la Neumatosis intestinal aislada o con gas en la vena porta puede estar asociada a diferentes condiciones clínicas, sin embargo, la asociación de Neumatosis intestinal, gas y trombosis portal es un hallazgo infrecuente.

We report a rare condition of Pneumatosis intestinalis with hepatic portal venous gas associated to portal thrombosis. A 37 years old female presented with abdominal pain andbloating from four days before admission. Blood pressure was 120/70 and body temperature normal. Physical examination revealed only abdominal tenderness. CT scan showed intestinalgas-filled cysts, air in portal venous system and thrombosis at portal vein branches. Treatment with oxygen and antibiotic therapy was followed by a clinical improvement and patient was discharged after 11 days. Several studies have reported Pneumatosis intestinalis alone and with Hepatic portal venous gas in different pathological conditions. HoweverPneumatosis intestinalis with hepatic portal venous gas associated with portal thrombosis is a unusual condition.

Hazards of nitrous oxide administration in presence of venous air embolism

Nitrous oxide administration in presence of venous air embolism results in its volume augmentation. The present case report of a 50-year old patient undergoing posterior fossa tumor excision in the sitting position demonstrates the hazards of nitrous oxide in presence of venous air embolism. Administration of 66% nitrous oxide 140 minutes after the incidence of air embolism resulted in a significant decrease of end-tidal carbon dioxide tension, moderate hypotension, and tachycardia, suggesting volume augmentation of the air embolism. The results of our case report are in contrast to that by Shapiro et al who noted that nitrogen washout following administration of 100% oxygen was complete 65 minutes after the occcurrence of venous air embolism. Shapiro and colleagues suggest the use of nitrous oxide challenge as a diagnostic aid in deciding when lung excretion of intravascular air is complete. However, our case report implies that nitrogen washout was not complete 140 minutes after venous air embolism incidence. Accordingly, we recommend to stop nitrous oxide administration once air embolism is suspected and to refrain from its readministration throughout the rest of surgery