Gas embolism during endoscopic retrograde cholangiopancreatography: diagnosis and management

Systemic air embolism associated with endoscopic retrograde cholangiopancreatography: A case report

BACKGROUND

Endoscopic retrograde cholangiopancreatography (ERCP) is a key procedure for diagnosing and treating biliary and pancreatic disorders. Although effective, it carries risks, including rare but severe complications such as air embolism.

CASE SUMMARY

We report a case of a 58-year-old man who developed extensive air embolism during ERCP. He previously underwent a Whipple procedure and experienced a sudden drop in vital signs and loss of consciousness. Immediate intervention with hyperbaric oxygen therapy and supportive care led to gradual recovery. Imaging confirmed widespread air embolism, which resolved with continued treatment.

CONCLUSION

Air embolism is a rare, critical complication of ERCP, especially in patients with prior surgery such as pancreaticoduodenectomy. Early detection and prompt treatment, including hyperbaric oxygen therapy, are crucial for favorable outcomes.

Gas Embolism Complicating Endoscopic Retrograde Cholangiopancreaticography: Case Report of a Complex Condition

This case report explores the complex clinical trajectory of a 72-year-old female with a history of hypertension, iron-deficiency anaemia, and vertigo, who underwent an endoscopic retrograde cholangiopancreaticography (ERCP) procedure for common bile duct (CBD) stone removal. After an uneventful laparoscopic cholecystectomy, she continued to experience abdominal pain and icterus. Investigations including magnetic resonance cholangiopancreatography (MRCP), revealed a dilated CBD with multiple stones, prompting ERCP. During the procedure, a fall in saturation and arrhythmia were noted, leading to the diagnosis of gas embolism. Trans-esophageal echocardiography (TEE) confirmed air bubbles in cardiac chambers and a patent foramen ovale (PFO). Despite interventions, including intubation, noradrenaline infusion, and a temporary pacemaker, the patient's cardiovascular status deteriorated. Due to financial constraints, she was discharged against medical advice (DAMA) with a high-risk profile. This case highlights the rarity and iatrogenic nature of ERCP-related air embolism, emphasising the challenges in its management and underscoring the need for awareness and timely intervention. The discussion delves into the broader context of air embolism pathogenesis, referencing relevant literature and highlighting the need for continued research in managing such rare complications associated with ERCP.

Analysis of Tomographic Images of a Catastrophic Gas Embolism during Endoscopic Retrograde Cholangiopancreatography

Endoscopic retrograde cholangiopancreatography (ERCP) is a commonly performed minimally invasive procedure. Air embolism in a patient undergoing ERCP is relatively rare, accounting for approximately 2-3% of procedures performed, and a catastrophic air embolism is even rarer. Symptoms of air embolism can come from the cardiopulmonary and nervous system. It is important to remember this in the differential diagnosis of complications of ERCP, as early detection is crucial. In the case presented here, the diagnostic CT scan performed immediately after the incident brings awareness of how massive an air embolism can be. The CT results showed gas bubbles entering both the superior and inferior vena cava. The presence of air has been captured in the bile ducts, duodenum wall, heart, femoral veins and intracranially. Risk factors for this complication include previous biliary surgeries, the presence of prostheses and stents, cholangitis, liver tumors and anatomical anomalies such as hepatobiliary fistulas, as well as intrahepatic and extrahepatic anatomical leaks. As gas embolism is associated with serious health consequences, knowledge of the problem and adequate preparation may reduce the occurrence of the problem. Attention should be paid to basic and easily obtainable precautions when performing the procedure, such as the patient's hemodynamic status, adequate hydration and positioning during the procedure.

Fatal Venous Gas Embolism During Endoscopic Retrograde Cholangiopancreatography After Simultaneous Deployment of 2 Self-Expandable Metallic Stents

Gas embolisms are a rare complication of endoscopic retrograde cholangiopancreatography (ERCP). While there have been multiple reports of ERCP-associated air embolisms, only 2 case reports using oral cholangioscopy and CO₂ insufflation have been reported in the literature. We present a unique case of a fatal CO₂ venous air embolism during ERCP without using cholangioscopy and with no intentional CO₂ insufflation of the biliary tree.

Translation from manual to automatic endoscopic insufflation enhanced by a pressure limiter

BACKGROUND

Optimal visualization and safety have always been essential in performing any type of endoscopic surgery. However, the safety of automatic gastrointestinal (GI) insufflation has yet to be thoroughly studied, especially when combined with manual insufflation. The current study aimed to verify whether the pressure limiter could lower GI endoluminal pressure during endoscopic procedures and affect the behavioral patterns of endoscopists.

METHODS

A preclinical blinded trial was conducted on endoscopists who had no knowledge regarding the presence of the pressure limiter that prevents a GI endoluminal pressure above 25 mmHg. Endoscopists in group A performed esophageal endoscopic submucosal dissection (ESD) with our insufflation device equipped with the pressure limiter, whereas those in group B performed the same procedure without the pressure limiter. During all procedures, endoluminal pressure was continuously monitored. The primary endpoint of the current study was to measure the endoluminal pressure with or without the pressure limiter during esophageal ESD, while the secondary endpoint was to evaluate the effect of the pressure limiter on intraesophageal pressure and perioperative outcomes during esophageal ESD. A questionnaire survey was conducted after each session.

RESULTS

A total of 79 endoscopists were included in this randomized control study. Group A had significantly lower endoluminal pressure than group B (10.6 ± 4.61 vs. 16.25 ± 7.51 mmHg, respectively; p < 0.05). Although two pigs in group B died from tension pneumothorax, none in group A died. Evaluation of lumen expansion, ease of aspiration, and visual field reproducibility were poorer in group A than in group B, although all fell within the acceptable range. Subjective evaluation of usability was divided into two categories, Excellent/Good and Poor/Bad, with no significant differences in any of the items.

CONCLUSIONS

This preclinical study showed that endoscopic treatment with an automatic insufflation system could be performed at lower endoluminal pressure with a pressure limiter, which had no adverse effects on the endoscopist's feels on endoscopic procedures with the device.

A case of posterior reversible encephalopathy syndrome during endoscopic retrograde cholangiopancreatography after anesthesia

Posterior reversible encephalopathy syndrome (PRES) is a neurological disorder that occurs following cerebral vasogenic edema. It has diverse clinical presentations from headache and vomiting to seizure and mental status alteration. Herein, we report a 54-year-old woman with no prior disease who developed PRES in the parieto-occipital lobes and brain stem after a second attempt endoscopic retrograde cholangiopancreatography (ERCP). To our knowledge, no case of PRES during ERCP has been reported to date. This case reminds us of unusual complications that are likely to occur after ERCP. It is believed that blood pressure fluctuations and anesthetic medications, fentanyl in particular, were the main precipitating factors causing the syndrome in the current case. Even if there is no specific treatment for this condition, a diagnosis is critical to start supportive treatment.

Cerebral Air Embolism After Gastrointestinal Procedure: A Case Report and Literature Review

Esophagogastroduodenoscopy (EGD) is one of the forefronts of minimally invasive modalities with excellent safety records and tremendous capability but despite its accolades and functions, there are still very rare complications including air embolism. It is a life-threatening condition that could lead to a significant increase in morbidity and mortality. However, there are limited data for incidence of air embolism in association with gastrointestinal endoscopy. Diagnosis of air embolism after or during gastrointestinal endoscopy might be a difficult task due to overlapping presentations with anesthesia effects on the cardiopulmonary and the neurological systems, as a result, there should be increased awareness allowing clinicians to quickly rule out air embolism in patient with altered mental status or cardiopulmonary changes after or during gastrointestinal endoscopy. Herein, we report a unique case of cerebral air embolism after EGD in a 79-year-old female patient. In addition, we also performed a systematic review of cases based on PRISMA guideline, with the aim to investigate the demographics and clinical outcomes associated with this complication. This systematic review of cases hopes to increase the awareness about this rare entity.

When in Trouble Think of the Bubble: Paradoxical Cerebral Arterial Gas Embolism after Endoscopic Retrograde Cholangiopancreatography

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.

[Intraoperative vascular air embolism : Evidence for risks, diagnostics and treatment]

The entry of gases into the vascular system is called vascular air embolism (VAE). The blocking of the pulmonary circulation by VAE can lead to fulminant right-sided heart failure and cardiocirculatory arrest. A VAE can occur at any time if there is an open connection between the environment and a venous vessel with subatmospheric pressure. This situation occurs during ear nose throat surgery, hip surgery, surgery of the lesser pelvis or breast surgery, if the surgical field is above the level of the heart; however, a VAE can also occur during routine tasks, such as insertion or removal of a central venous catheter or during endoscopic procedures with the insufflation of gas.Because during these procedures VAE is not the main focus of the anesthesia or surgery personnel, in such situations its sudden unexpected occurrence can have severe consequences. In contrast, in cardiac surgery or neurosurgery the risk of intraoperative VAE is much better known. In procedures with a higher risk of a clinically relevant VAE, a patent foramen ovale should be ruled out by preoperative transesophageal echocardiography (TEE). Intraoperatively TEE is the most sensitive procedure not only to detect a VAE but also to visualize the clinical expression, e.g. acute right heart overload.The avoidance of an initial and repeated air embolism is the primary measure to minimize the incidence and severity of VAE.Intraoperatively the following measures should be undertaken: excellent communication between anesthesia and surgery personnel with predetermined actions, maintenance of normal volume, patient positioning with minimal difference in height between heart and head, state of the art surgical technique with closure of potential air entry sites, sufficient detection of air by TEE, repeated jugular vein compression during neurosurgery, intraoperative Trendelenburg positioning of the patient during persisting or clinically evident VAE, differentiated adjustment of ventilatory settings and catecholamine treatment, aspiration of the blood-air mixture (air lock) at the junction of the superior vena cava and right atrium through a large bore central venous line and keeping check of the coagulation status.

Critical Analysis of Guidelines for Providing Sedation to Patients Undergoing Gastrointestinal Endoscopy Procedures

In spite of growing numbers of gastrointestinal endoscopic procedures performed under deep sedation, guidelines are lacking. Hypoxemia and aspiration continue to be the main source of morbidity. Anesthesia providers have tried to address these concerns by modifying their technique and employing newer or improvised devices. In addition, preprocedural evaluation poses many challenges. In many centers, workload pressures determine the time available to perform such an evaluation. A comprehensive history and examination similar to a major surgical procedure is often not possible. As a result, a focused history and examination is essential. This should be followed by an appropriate explanation of risks before obtaining consent. A plan should be in place to manage complications such as aspiration. This paper provides a succinct review of the above aspects.

Clinical Presentation, Diagnosis, and Management of Air Embolism During Endoscopic Retrograde Cholangiopancreatography

Endoscopic retrograde cholangiopancreatography (ERCP) is a minimally invasive procedure that is widely used by endoscopists and has a robust therapeutic profile. It uses endoscopy and imaging for a variety of diagnostic as well as therapeutic purposes. It is used for the management of a lot of pancreaticobiliary diseases such as obstructive jaundice, obstruction related to bile ducts, pancreatic biliary tumors, and traumatic or iatrogenic damage to the bile ducts. Other therapeutic interventions that can be done via ERCP include sphincterotomy, dilation of strictures, removal of biliary stones and placement of stents. Air embolism presents with cardiovascular, pulmonary, and neurologic signs and symptoms. Treatment of air embolism should be started early in suspected cases, and it should be in the differential diagnoses of various complications secondary to high risk of ERCP, especially if a cardiopulmonary compromise is present. Air embolism is rare but a serious complication associated with ERCP. The physicians must keep this in mind while performing ERCP in patients with predisposing risk factors. This review highlights the mechanism, causes, risk factors, pathophysiology, clinical signs, diagnostic modalities, treatment, and preventive measures to deal with this catastrophic complication.