Document Detail


Fatal systemic venous air embolism during endoscopic retrograde cholangiopancreatography.
MedLine Citation:
PMID:  19546613     Owner:  NLM     Status:  MEDLINE    
Abstract/OtherAbstract:
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.
Authors:
Michele Bisceglia; Anna Simeone; Rosario Forlano; Angelo Andriulli; Alberto Pilotto
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Publication Detail:
Type:  Case Reports; Journal Article    
Journal Detail:
Title:  Advances in anatomic pathology     Volume:  16     ISSN:  1533-4031     ISO Abbreviation:  Adv Anat Pathol     Publication Date:  2009 Jul 
Date Detail:
Created Date:  2009-06-23     Completed Date:  2009-08-27     Revised Date:  -    
Medline Journal Info:
Nlm Unique ID:  9435676     Medline TA:  Adv Anat Pathol     Country:  United States    
Other Details:
Languages:  eng     Pagination:  255-62     Citation Subset:  IM    
Affiliation:
Department of Pathology, Division of Digestive Endoscopy, IRCCS-Casa Sollievo della Sofferenza Hospital, Viale Cappuccini, San Giovanni Rotondo (FG), Italy. bismi@libero.it
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MeSH Terms
Descriptor/Qualifier:
Aged
Autopsy
Biliary Fistula / complications*,  radiography
Cholangiopancreatography, Endoscopic Retrograde / adverse effects*
Duodenal Diseases / complications*,  radiography
Embolism, Air / etiology*,  radiography
Fatal Outcome
Gallstones / radiography,  surgery
Hepatic Veins / radiography
Humans
Intestinal Fistula / complications*,  radiography
Intracranial Embolism / etiology*,  radiography
Male
Phlebography
Portal Vein / radiography
Portography
Pulmonary Embolism / etiology*,  radiography
Tomography, X-Ray Computed

From MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine


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