Advanced Endoscopy Fellows Program | September 2022-Draganov

Draganov_Clinical Cases
Pdf Summary
Case #1 involves a 47-year-old female with acute pancreatitis and elevated amylase and lipase levels. Further tests reveal normal liver function and non-dilated bile ducts. The next step is a right upper quadrant ultrasonography (RUQ US), followed by magnetic resonance cholangiopancreatography (MRCP), and then endoscopic retrograde cholangiopancreatography (ERCP). Sphincterotomy is done during the ERCP procedure. The patient is diagnosed with anomalous pancreatobiliary junction (APBJ) without a type I choledochal cyst, which is associated with gallbladder cancer. Prophylactic cholecystectomy is recommended.<br /><br />Case #2 involves a 66-year-old male who had a Whipple surgery for pancreatic cancer a year ago. The patient has elevated bilirubin levels and an MRCP suggests a stricture at the choledochojejunostomy. However, the patient also has hyponatremia with a serum sodium level of 114 mmol/L. The potential cause of the hyponatremia is pseudo-hyponatremia due to elevated lipids and the accumulation of lipoprotein X caused by biliary obstruction.<br /><br />During the ERCP procedure, the patient experiences complications after the change in position from prone to supine. The complications include oxygen desaturation, ocular deviation, and forehead skin discoloration. The differential diagnoses for these symptoms include cerebral arterial air embolism. CT chest angiography and head CT confirm the presence of air in the cerebral arterial system. Further investigation with a transthoracic echocardiogram reveals left-sided intracardiac air and a patent foramen ovale. Risk factors for air embolism during ERCP include prior pancreaticobiliary surgery, percutaneous transhepatic cholangiography (PTC), transjugular intrahepatic portosystemic shunt (TIPS) placement, liver biopsy, cholangioscopy, and prolonged procedure duration.<br /><br />The treatment for air embolism includes placing the patient in the Trendelenburg and left lateral decubitus position, administering high-flow oxygen, and providing aggressive intravenous fluids. If right heart air is observed, air aspiration via a central venous catheter may be considered. Urgent hyperbaric oxygen therapy is also recommended.<br /><br />In conclusion, Case #1 involves the management of APBJ without a type I choledochal cyst, while Case #2 discusses the potential cause of hyponatremia and the complications of air embolism during ERCP.
Keywords
acute pancreatitis
RUQ US
MRCP
ERCP
anomalous pancreatobiliary junction
choledochal cyst
gallbladder cancer
hyponatremia
lipoprotein X
air embolism