PICTURES IN DIGESTIVE PATHOLOGY

 

Portal air embolism after endoscopic retrograde cholangiopancreatography

 

 

Sandra Barbeiro, Catarina Atalaia-Martins, Cláudia Gonçalves and Isabel Cotrim

Department of Gastroenterology. Centro Hospitalar de Leiria. Leiria, Portugal

 

 

Case report

A 72-year-old woman presented with jaundice. A contrast-enhanced tomography (CT) showed dilation of the biliary ducts with no obstructive cause. Endoscopic retrograde cholangiopancreatography (ERCP) with a pre-cut papillotomy was performed, allowing smooth guide wire progression through what looked like the biliary tract. On cholangiogram, the opacification of bile ducts was brief, followed by rapid contrast washout, raising the possibility of contrast injection into vascular branches (Figs. 1 and 2). The procedure was immediately suspended. The patient was asymptomatic and no bleeding was observed. A CT angiogram showed air in the small portal branches of both hepatic lobes and in the retroperitoneum (Fig. 3). The patient's general condition was stable and intravenous antibiotics was started. Blood samples revealed a 1.5 g/dl decrease in hemoglobin. A CT scan performed after 48h indicated significant improvement. The patient was discharged after eight days.

 

 

 

 

Discussion

Portal venous gas and contrast opacification during ERCP is a rare complication, described in one of 6,000-8,000 procedures (1,2). Portal vein cannulation results from vascular laceration during pre-cut papillotomy/sphincterotomy or due to portobiliary fistulas associated with tumor infiltration or abscesses (1,2). Most cases reported had no serious morbidity or mortality although this complication carries potential life threatening consequences (1,3).

This report demonstrates that portal vein cannulation may be a source of confusion because the guided wire trajectory inside the portal vein may be similar to that of the biliary, and a contrast washout/opacified portal vein may be misinterpreted as an incompletely filled bile duct. Vascular cannulation should be promptly recognized and the procedure must be immediately suspended.

 

References

1. Espinel J, Pinedo ME, Calleja JL. Portal vein filling: An unusual complication of needle-knife sphincterotomy. Endoscopy 2007;39(Suppl 1):E245. DOI: 10.1055/s-2007-966156.         [ Links ]

2. Kalaitzakis E, Stern N, Sturgess R. Portal vein cannulation: An uncommon complication of endoscopic retrograde cholangiopancreatography. World J Gastroenterol 2011;17:5131-2. DOI: 10.3748/wjg.v17.i46.5131.         [ Links ]

3. Kawakami H, Kuwatani M, Kudo T, et al. Portobiliary fistula: Unusual complication of wire-guided cannulation during endoscopic retrograde cholangiopancreatography. Endoscopy 2011;43(Suppl 2). DOI: 10.1055/s-0030-1256150.         [ Links ]