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Ekmektzoglou K, Alexandrakis G, Dimopoulos K, Tsibouris P, Kalantzis C, Vlachou E, Apostolopoulos P. When in Trouble Think of the Bubble: Paradoxical Cerebral Arterial Gas Embolism after Endoscopic Retrograde Cholangiopancreatography. Case Rep Gastroenterol 2021; 15:456-469. [PMID: 34054400 PMCID: PMC8138231 DOI: 10.1159/000514706] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Accepted: 01/22/2021] [Indexed: 11/19/2022] Open
Abstract
Air embolism (a result of direct communication with the vasculature and an external pressure gradient from the gastrointestinal or the biliary tract), although rare, is a potentially devastating adverse event seen in endoscopic retrograde cholangiopancreatography (ERCP) procedures. Whether venous, arterial, or paradoxical, the clinical presentation ranges from asymptomatic patients to cardiorespiratory arrest. This is of particular importance because it makes the diagnosis of air embolism even more difficult in an already sedated patient. Since early recognition increases the chances of patients' survival, endoscopists should be highly motivated and trained to recognize this complication as early as possible. With only 60 cases of air embolism reported (and even fewer related to paradoxical air embolism), we aimed to report a case of paradoxical cerebral air embolism in a patient undergoing ERCP due to a common bile duct stricture and to provide a mini-review of this clinical entity that can serve as a bedside quick reference guide for endoscopists worldwide.
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Affiliation(s)
- Konstantinos Ekmektzoglou
- School of Medicine, European University Cyprus, Nicosia, Cyprus.,Department of Gastroenterology, Army Share Fund Hospital, Athens, Greece
| | | | | | | | | | - Erasmia Vlachou
- Department of Gastroenterology, Army Share Fund Hospital, Athens, Greece
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Lanke G, Adler DG. Gas embolism during endoscopic retrograde cholangiopancreatography: diagnosis and management. Ann Gastroenterol 2018; 32:156-167. [PMID: 30837788 PMCID: PMC6394273 DOI: 10.20524/aog.2018.0339] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2018] [Accepted: 10/12/2018] [Indexed: 12/20/2022] Open
Abstract
Air embolism is rarely diagnosed and is often fatal. The diagnosis is often not made in a timely manner given the rapid and severe clinical deterioration that often develops, frequently leading to cardiac arrest. Many patients are only diagnosed post-mortem. With the increasing use of endoscopic retrograde cholangiopancreatography, air embolism should be considered in the differential diagnosis in patients who experience sudden clinical deterioration during or immediately after the procedure. Clinical suspicion is key in the diagnosis and management of air embolism. Use of precordial Doppler ultrasound and transesophageal echocardiogram can aid in the diagnosis of air embolism. Once the diagnosis is made, supportive management of airway, breathing and circulation is pivotal. Advanced cardiac life support should be initiated when necessary. Fluid resuscitation and vasopressors can improve cardiac output. Hyperbaric oxygen therapy should be considered when possible in cases of suspected cerebral air embolism cases to improve neurological outcome. A multidisciplinary team approach and effective communication with experts, potentially including an anesthesiologist, cardiologist, intensivist, radiologist and surgeon, can improve the outcome in air embolism.
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Affiliation(s)
- Gandhi Lanke
- Plains Regional Medical Center, Clovis, New Mexico (Gandhi Lanke), USA
| | - Douglas G Adler
- Department of Gastroenterology and Hepatology, University of Utah School of Medicine, Salt Lake City, Utah (Douglas G. Adler), USA
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Bastovansky A, Stöllberger C, Finsterer J. Fatal Cerebral Air Embolism Due to a Patent Foramen Ovale during Endoscopic Retrograde Cholangiopancreatography. Clin Endosc 2014; 47:275-80. [PMID: 24944995 PMCID: PMC4058549 DOI: 10.5946/ce.2014.47.3.275] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2013] [Revised: 12/25/2013] [Accepted: 12/27/2013] [Indexed: 02/07/2023] Open
Abstract
Fatal air embolism to the cerebrum during an endoscopic retrograde cholangiopancreatography (ERCP) has not been reported in a patient with a biliodigestive anastomosis and multiresistant extended-spectrum β-lactamase Escherichia coli (ESBL) bacteremia. A 59-year-old woman with a history of laparoscopic cholecystectomy and iatrogenic injury of the right choledochal duct, choledochojejunostomy (biliodigestive anastomosis), recurrent cholangitis, revision of the biliodigestive anastomosis, recurrent liver abscesses, and recurrent stenting of stenotic bile ducts, was admitted because of fever and tenderness of the right upper quadrant. On ERCP, a previously deployed covered Wallstent was replaced. Blood cultures grew ESBL. After stent removal 8 days later, the patient did not wake up and developed arterial hypotension and respiratory insufficiency, requiring mechanical ventilation. Computed tomography scans showed extensive air embolism to the liver, heart, and cerebrum. She died 1 day later. Although the exact pathogenesis of the fatal cerebral air embolism remains speculative, the nonphysiological anatomy and chronic infection with ESBL may have been contributory factors.
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Chavalitdhamrong D, Donepudi S, Pu L, Draganov PV. Uncommon and rarely reported adverse events of endoscopic retrograde cholangiopancreatography. Dig Endosc 2014; 26:15-22. [PMID: 24118211 DOI: 10.1111/den.12178] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2013] [Accepted: 08/21/2013] [Indexed: 02/06/2023]
Abstract
Endoscopic retrograde cholangiopancreatography (ERCP) has become a primary tool for the treatment of biliary and pancreatic ductal diseases. It is essential for the endoscopist carrying out the ERCP to have a thorough understanding of the potential adverse events. Typically, endoscopists are well familiar with common adverse events such as post-ERCP pancreatitis, cholangitis, post-sphincterotomy bleeding, post-sphincterotomy perforation, and sedation-related cardiopulmonary compromises. However, there are other less common adverse events that arecritical to promptly recognize in order to provide appropriate therapy and prevent disastrous outcomes. This review focuses on the presentation and management of the less common and rare adverse events of an ERCP from the perspective of the practicing endoscopist.
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Affiliation(s)
- Disaya Chavalitdhamrong
- Division of Gastroenterology, Hepatology, and Nutrition, University of Florida, Gainesville, USA
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Pan Y, Qiu B, Yu F, Hu B. Fatal air embolism during endoscopic retrograde cholangio-pancreatography (ERCP): a case report. ACTA ACUST UNITED AC 2012. [DOI: 10.1016/s1000-1948(12)60024-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
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[Iatrogenic gas embolism during upper gastroscopy in a patient with a multiperforated biliary drain placed by radiological way]. ACTA ACUST UNITED AC 2012; 31:724-7. [PMID: 22749549 DOI: 10.1016/j.annfar.2012.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2011] [Accepted: 04/03/2012] [Indexed: 11/21/2022]
Abstract
The authors report the first case of gas embolism arising during an upper gastrointestinal endoscopy to a patient carrier of a biliary drain placed by radiological way. The hypothesis of a biliary-vascular fistula with abnormal connection between the biliary tree and the hepatic vascular system and finally an arteriovenous intrapulmonary shunt was retained to explain the physiopathology. The immediate stop of the endoscopic procedure and the implementation of symptomatic treatment allowed a favorable neurological outcome without sequelas. The realization of an upper gastrointestinal endoscopy to a patient carrier of a biliary drain has to lead the anaesthesiologists and the gastroenterologists to take care given the incurred risk of gas embolism.
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Abstract
Regional or systemic air embolism to the heart or cerebrum during endoscopic retrograde cholangio-pancreatography (ERCP) is an increasingly recognized phenomenon. This review aims to give an overview about the current knowledge concerning pathomechanism, diagnosis, treatment, and outcome of air embolism during ERCP. A Medline search was carried out for the key words 'ERCP' in combination with 'liver dysfunction', 'air embolism', 'complication', and 'side-effect'. Altogether 18 reports about 19 patients were found matching with the key words and the topic of interest. Systemic air embolism after ERCP occurred in 14 cases and was associated with cerebral air embolism in eight of them. In six cases with cerebral air embolism the outcome was fatal. Only two patients with cerebral air embolism survived, one of them without a deficit and one with hemiparesis. In only two cases, transgression of air from the venous to the arterial branch occurred through a patent foramen ovale. In none of the patients was transgression attributable to arterio-venous shunts within the lung or other tissues, the Thebesian veins, or insertion of the caval veins directly into the left atrium. In five patients, systemic air embolism occurred in the absence of a foramen ovale. In all these cases it was assumed that air entered the vasculature through the portal or hepatic veins. In conclusion, if patients do not awake after ERCP air embolism should be considered, an acute cerebral and thoracic computed tomography scan should be ordered, and appropriate measures, including aspiration of air from the right ventricle through an acutely floated pulmonary artery catheter or hyperbaric oxygenation initiated.
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Romberg C. Systemic air embolism after ERCP: a case report and review of the literature (with video). Gastrointest Endosc 2009; 70:1043-5. [PMID: 19577747 DOI: 10.1016/j.gie.2009.03.028] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2009] [Accepted: 03/13/2009] [Indexed: 02/08/2023]
Affiliation(s)
- Christopher Romberg
- Department of Gastroenterology, Kaiser Permanente Los Angeles Medical Center, Los Angeles, California 90027, USA
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Fatal systemic venous air embolism during endoscopic retrograde cholangiopancreatography. Adv Anat Pathol 2009; 16:255-62. [PMID: 19546613 DOI: 10.1097/pap.0b013e3181aab793] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Hepatic portal venous air embolism is the rarest complication of gastrointestinal endoscopy, resulting from penetration of gas into the portal veins, and may occur during endoscopic retrograde cholangiopancreatography and endoscopic biliary sphincterotomy. The likely mechanism is intramural dissection of insufflated air into the portal venous system through duodenal vein radicles transected during the procedure. Hepatic portal air embolism may be fatal. Cerebral air embolism may also occur. So far 13 cases of air embolism after endoscopic retrograde cholangiopancreatography have been reported, with 4 cases of systemic spread that proved fatal. Death was due to pulmonary air embolism in 2 cases, and cerebral air embolism in another 2. We report on an additional such fatal case, concerning a 78-year-old male patient, who several years previously had undergone surgical gastroduodenal resection with cholecystectomy and papillotomy, and was admitted for recurrent ascending cholangitis secondary to bile duct stones. During the third endoscopic cholangioscopic procedure for removal of bile duct stones, sudden cardiopulmonary arrest occurred. Death was due to massive pulmonary air embolism. Cerebral air embolism was also found. Autopsy was performed. A spontaneous duodenobiliary fistula was found. On the basis of bench radiologic investigation (retrograde suprahepatic venography and anterograde portography), it was demonstrated that the air insufflated during duodenal endoscopy, which entered through the spontaneous duodeno-biliary fistula, penetrated into intrahepatic vein radicles injured secondarily to prolonged impaction of biliary sand and stones and infection, resulting in portal and hepatic venous gas and systemic air embolism.
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Tan BK, Saunier CF, Cotton F, Gueugniaud PY, Piriou V. [Thoracoabdominal CT scan: a useful tool for the diagnosis of air embolism during an endoscopic retrograde cholangiopancreatography]. ACTA ACUST UNITED AC 2008; 27:240-3. [PMID: 18313255 DOI: 10.1016/j.annfar.2007.12.015] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2007] [Accepted: 12/19/2007] [Indexed: 02/07/2023]
Abstract
We report the case of an 82-year-old woman treated with biliary stents for an ampulloma of Vater's papilla, with recurrent stenosis of the common bile duct. She was hospitalized with a cholestasis. An endoscopic retrograde cholangiopancreatography (ERCP) was scheduled to change the biliary stent for a metallic one, under general anaesthesia, with oral intubation. The ERCP was performed initially without any complication, but as the metallic biliary stent was placed, an air embolism occurred and a cardiac arrest happened immediately. The etiologic diagnosis was quickly confirmed by an injected multislice body-scan, which showed liver, right heart and brain gas embolism. Cardiopulmonary resuscitation allowed a complete haemodynamic recovery but a poor neurological recovery. The patient was transferred in intensive care unit, were she died 12 days after, despite hyperbaric oxygen therapy and the disappearance of the air embolism on the following computed tomography scan. This case may be useful to recall the utility of a body-scan for the diagnosis, treatment and follow-up of an air embolism during ERCP.
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Affiliation(s)
- B K Tan
- Service d'anesthésie-réanimation, centre hospitalier Lyon-Sud, université Claude-Bernard, Lyon-1, 69395 Pierre-Bénite cedex, France
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