Case report 1
Cerebral gas embolism due to upper gastrointestinal endoscopy Mark ter Laana, Erik Tottea, Rob A. van Hulstd, Klaas van der Lindeb, Wim van der Kampc and Jean-Pierre E. Pieriea Cerebral gas embolism as a result of upper gastrointestinal endoscopy is a rare complication and bares a high morbidity. A patient is presented who underwent an upper endoscopy for evaluation of a gastric-mediastinal fistula after subtotal oesophagectomy and gastric tube reconstruction because of oesophageal cancer. During the procedure, cerebral gas emboli developed resulting in an acute left-sided hemiparesis. After hyperbaric oxygen therapy, the patient recovered almost completely. The aetiology and treatment is discussed based on the reviewed literature. Once cerebral gas emboli are recognized, patient outcome can be improved by hyperbaric oxygen therapy. Eur J Gastroenterol Hepatol c 2009 Wolters Kluwer Health | Lippincott 00:000–000 Williams & Wilkins.
Introduction Cerebral gas embolism (CGE) is an uncommon (often iatrogenic) event, which can result in significant morbidity and even mortality. It is a well documented complication of various procedures like venous access surgery, (neuro)surgical interventions with the patients in the sitting position, hysteroscopy, bronchoscopy, positive pressure ventilation, cardiac and laparoscopic surgery [1].
European Journal of Gastroenterology & Hepatology 2009, 00:000–000 Keywords: endoscopy, gas embolism, gastrointestinal hyperbaric oxygenation Departments of aSurgery, bGastroenterology, cNeurology, Medical Center Leeuwarden, Leeuwarden and dDiving Medical Center, Royal Netherlands Navy, The Netherlands Correspondence to Mark ter Laan, MD, Medical Center Leeuwarden, Henri Dunantweg 2, PO Box 888, Leeuwarden 8901 BR, The Netherlands Tel: + 31 58 286 3813; e-mail:
[email protected]
Received 8 June 2008 Accepted 14 July 2008
Fig. 1
We report a case of CGE in a patient undergoing a diagnostic upper gastrointestinal endoscopy after transhiatal subtotal oesophagectomy and gastric tube reconstruction for a T3N1M0 distal adenocarcinoma of the oesophagus. We will discuss causes of CGE and treatment options, and we will present a review of the literature of CGE in upper endoscopy. Case presentation
A 48-year-old male underwent open transhiatal subtotal oesophagectomy with tubular gastro-oesophageal reconstruction as curative treatment for a T3N1M0 adenocarcinoma of the distal oesophagus. The postoperative course was complicated by a fistula between the cervical gastric-oesophageal anastomosis and mediastinum with leakage to the pleural space (Fig. 1). An upper endoscopy was performed to evaluate whether it could be treated by placing a self-expandable stent, by insufflating the stomach and rinsing the fistula orifice with tap water. During the procedure, the patient developed an acute left-sided hemiparesis. Neurological examination revealed a drowsy patient with a Glasgow Coma Score of c 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins 0954-691X
Barium swallow examination of our patient showing leakage of barium contrast fluid into the mediastinal and pleural spaces (white arrows). Black arrows indicate the gastric tube reconstruction.
DOI: 10.1097/MEG.0b013e328310aefc
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2 European Journal of Gastroenterology and Hepatology 2009, Vol 00 No 00
Fig. 2
Computed tomography scan of the brain of our patient showing multiple gas emboli (arrows) in the right hemisphere.
E2 M6 V2. A left sided hemiparesis grade 3 with hyperreflexia and a Babinski’s sign was observed. A high-resolution computed tomography scan of the brain showed a hypodense area of the right frontal lobe and multiple gas emboli (Fig. 2).
Discussion
Within 24 h the patient was referred for hyperbaric oxygen (HBO) therapy at a diving medical centre. The treatment included recompression with HBO at a depth of 18 m during 5 h. The treatment was complicated by a short epileptic insult 2 h after starting recompression. It was successfully treated with diazepam. The next day, another treatment with HBO at 9 m depth for 3 h was performed.
Venous gas embolism occurs when gas enters the venous system. The gas is trapped in the arterioles in the lung, which may lead to decreased gas exchange. Most venous gas is filtered in the pulmonary capillary bed, but ‘paradoxical emboli’ may occur when this filter system overloads resulting in arterial gas embolism. Gas may also enter the arterial vasculature directly during surgery or through a cardiac shunt, for example, a persistent foramen ovale. Arterial gas emboli may cause ischaemia in end organs. Especially, arterial CGE can cause severe morbidity because of the brain’s high oxygen demands and minor collateral circulation.
After treatment the neurological examination showed a slight residual hemiparesis of the left side. At follow up, 3 weeks later, the symptoms were almost completely resolved and the fistula had healed by conservative measures.
In the presented patient, no cardiac shunt was found by echocardiography. Most likely paradoxical emboli have developed as a result of massive gas entrance during insufflation and irrigation of the fistula during endoscopy.
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Cerebral gas embolism in upper endoscopy Laan et al. 3
Table 1
Earlier cases of cerebral gas embolism in upper gastrointestinal endoscopy
Reference
Sex/age (years)
Treatment
Akhtar, et al. [5] Bou-Samra, et al. [6]
F/80 M/66
Christl, et al. [7] Demaerel, et al. [8]
F/66 M/80
Green and Tendler [9] Mellado [10] Nayagam [11] Rabe, et al. [12]
M/71 F/52 M/56 M/87
100% Oxygen 100% Oxygen, hyperventilation, decadron, mannitol None None (hyperbaric oxygen not available) Hyperbaric oxygen 100% Oxygen 100% Oxygen Mechanical ventilation
Raju [13]
M/75
Hyperbaric oxygen
Stabile, et al. [14]
M/65
Cardiopulmonary resuscitation
Outcome
Risk factor
Persistent vegetative state Death
Oesophageal biopsy Gastric erosions
Death Left hemiparesis
Duodenocaval fistula None
Paresis of left arm Death Death Left hemiparesis
Balloon dilatation Oesophagitis ERCP after earlier biliary stent Patent foramen ovale and ERCP after earlier biliary stent Balloon dilatation and oesophageal biopsy ERCP after earlier PTBD
Death from septic shock following aspiration Death
ERCP, endoscopic retrograde cholangiopancreatography; F, female; M, male; PTBD, percutaneous transhepatic biliairy drainage.
We reviewed the literature and found another 10 cases in which CGE developed as a complication of upper endoscopy (including endoscopic retrograde cholangiopancreaticography) (Table 1). Morbidity and mortality is extremely high, but can be reduced by prompt treatment with HBO; preferably within 24 h [1]. In the acute phase of CGE, ischaemia occurs because of vascular occlusion by gas bubbles. These bubbles will decrease in size in the following hours because of diffusion into the surrounding tissue [2]. Compression of the bubbles by hyperbaric therapy increases diffusion and subsequently will decreases the ischaemic period, whereas oxygenation of the hypoxic tissues can be achieved by the high oxygen concentration [3]. The gas bubbles can also cause damage to the vascular endo thelium, increased platelet aggregation, temporary distortion of the blood–brain barrier and cytotoxic oedema [4]. CGE is a very rare complication of upper gastrointestinal endoscopy, with high mortality.
aggressive use of HBO therapy is paramount to improving patient outcome.
Conclusion CGE is a rare but serious complication of gastrointestinal endoscopy. Early recognition of symptoms and early start of treatment with HBO favours the patients’ outcome.
Acknowledgement Conflict of interest: none declared.
References 1 2
3
4 5 6
In upper endoscopy, some risk factors are likely to be associated with gas emboli, including gastric erosions, balloon dilatation, taking biopsies and sphincterotomy or earlier hepatic injury in endoscopic retrograde cholangiopancreaticography. Given the rarity of this complication, it is impossible to recommend measures that may prevent air embolism from occurring. It is also impractical to screen all patients for cardiac shunting before performing endoscopy.
7 8
9 10 11
12
No consensus about how long the delay may be between embolization and HBO treatment is present. Although prompt HBO intervention is likely to lead to better neurological recovery, successful treatment has been reported in patients even after a delay of 6–24 h [1]. Therefore, early recognition of suggestive symptoms and
13
14
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