Rare But Fatal Complication of Endoscopic Variceal Band Ligation, Air Embolism

Abstract

Introduction: Esophagogastroduodenoscopy (EGD) is a routinely performed procedure for various reasons. Air embolism is considered to be catastrophic complication with reported mortality as high as 57%. We present this case for clinicians to consider air embolism as cause of post procedure encephalopathy in routine endoscopic procedures.Figure 1Case: This is a 60-year-old Caucasian male with a history of hepatocellular carcinoma on the transplant list, hepatitis C virus with cirrhosis complicated by esophageal varices and splenomegaly was admitted for melena and confusion. CT head on admission was unremarkable. EGD was performed that showed grade IV esophageal varices with nipple sign, blood in pharynx and esophagus, and portal hypertensive gastropathy. Patient underwent band ligation. Post procedure, patient was found to be unresponsive and not moving any extremities. CT head was ordered and showed air embolism. Patient was unstable for transport to a facility for hyperbaric oxygen therapy. Family decided to pursue Palliative withdrawal of care and patient eventually died during the admission. Methods: Patient's chart, Radiological findings, Procedural findings, Laboratory findings, and Consultant's notes Results: See Figures attached Discussion: Nine reported cases of cerebral air embolism in literature. Two factors are required for the occurrence of an air embolism: a communication between an air source and the vasculature, and a pressure gradient favoring passage of air into the circulation. EGD requires air insufflation and thus creates the pressure gradient necessary to favor the passage of air into the vasculature. Hopkins et al found that 47% of patients with chronic liver disease possess an intrapulmonary right to left shunt. In our patient there were multiple potential risk factors: insufflation of air with high pressure, excessive amount and/or increased rate of air infusion, procedural site located higher than the level of the heart with history of cirrhosis. We ask to consider cerebral air embolism in patient with post endoscopy encephalopathy since rapid diagnosis is essential. CT head is best imaging modality given its access and quick results. Treatment involves hyperbaric oxygen, when available.