Fatal hepatic air embolism following ERCP

Abstract

Colette Kennedy, MD Mike Larvin, MD Jane Linsell, MD Portal venous gas has been frequently reported in both children and adults with mesenteric ischemia and intra-abdominal sepsis, and following barium en- ema and colonoscopy. Hepatic portal venous gas is a rare complication following ERCP with sphincterot- omy. It has only been described in single case reports, and in each incidence the patient was treated conser- vatively with a successful outcome. 4-6 A search of the English literature revealed no record of fatal portal and hepatic venous gas. We wish therefore to describe a case in which endoscopic sphincterotomy was com- plicated by rapidly fatal portal and hepatic venous air embolism. CASE REPORT A 63-year-old woman was referred to the emergency de- partment by her general practitioner with a 1-week history of central abdominal pain, anorexia, nausea and vomiting, and a 2-day history of jaundice with dark urine: She was known to be hypertensive, had atrial fibrillation, and had a transient ischemic attack 3 years previously; she was not receiving anticoagulants. On physical examination she was noted to be jaundiced with mild epigastric tenderness. Her liver function tests on admission were elevated as follows: bilirubin 52 gmol/L (normal: 2 to 22), alkaline phosphatase 137 IU/L (normal: 38 to 126), and alanine transferase 70 IU/L (normal 14 to 56). She had a normal hemoglobin level of 13.6 gm/dL and a normal clotting profile (prothrombin time 13 seconds, control 11 seconds; partial thromboplastin 34 seconds, control 31 seconds). Ultrasound showed a con- tracted gall bladder with multiple calculi and a dilated com- mon bile duct of 12 mm diameter, with a 10 mm stone in the distal duct. Twenty-four hours after admission she became febrile but her fever decreased with intravenous antibiotics (gentamicin and cefuroxime). ERCP was performed following sedation with 10 mg mi- dazolam, 50 mg meperidine, and 40 mg hyoscine butylbro- mide (Buscopan). Cannulation was difficult because of a large and dependent papilla. The cholangiogram confirmed the pres-