Acute respiratory distress syndrome following esophageal varice sclerotherapy

Abstract

We report serious pleuropulmonary complications in a 6-year-old girl with an underlying extrahepatic biliary atresia who underwent esophageal varice sclerotherapy (EVS). The EVS was performed paravariceally with a 25-gauge disposable injection needle using polidocanol as a sclerosant. A total of 11 ml of the agent was injected in this session. The patient reported epigastric pain and developed a high fever with tachypnea at 11 and 17 h after the procedure, respectively. After 72 h following the EVS, she became dyspnic and required much more oxygen therapy. A follow-up chest X-ray revealed a moderate right pleural effusion and widening of the mediastinum. The arterial blood gas, obtained during FiO 2 of 0.8, revealed PaO 2 of 123 mmHg. Bilateral alveolar infiltration was noted in the follow-up chest X-rays. Acute respiratory distress syndrome (ARDS) was diagnosed. She was supportively treated with mechanical ventilator, broad-spectrum antibiotics, and right chest drainage. The patient was discharged home after a 3-week hospitalization with propranolol prophylaxis. A pathogenesis of ARDS following EVS was reviewed.at the age of 40 days, presented with a history of melena. She was supportively treated with multiple blood transfusions before referral to our hospital, where propronolol was prescribed while she was being scheduled for an elective endoscopic intervention as a secondary prophylaxis. On this admission, she was moderately malnourished. Her body weight and height were 17.5 kg and 106.5 cm, respectively. Physical examination revealed jaundice and marked splenomegaly with signs of chronic liver diseases. The complete blood count (CBC) showed mild anemia (hemoglobin, 8.9 g/ dl) and thrombocytopenia (platelets, 74 000/mm 3 ). The coagulograms were mildly abnormal. The liver function tests revealed albumin/globulin, 3.3/3.7 g/dl; alkaline phosphatase, 687 IU/l; cholesterol, 99 mg/dl; aspartate transaminase/alanine transaminase (AST/ALT), 74/32 IU/l; and total bilirubin/direct bilirubin (TB/DB), 7.75/4.48 mg/dl. Esophagogastroduodenoscopy was carried out under general anesthesia. There were three medium to large sized, tortuous, and bluish esophageal varices noted at the esophago-gastric (EG) junction without evidence of recent or active bleeding. The gastric folds appeared thickened with mosaic pattern of gastric mucosa. Neither ulcer, gastric varice, nor duodenal varice was observed. Esophageal varice sclerotherapy (EVS) was performed paravariceally with a 25-gauge disposable injection needle using polidocanol (1% Aethoxysklerol; Chemische Fabrik, Wiesbaden, Germany) as a sclerosant. A total of 11 ml of the agent (0.63 ml/kg) was injected in this session. No immediate complication was noted.Eleven hours after the procedure, the patient reported epigastric pain that was supportively treated with antacid and ranitidine. Six hours later, she developed a high fever and tachypnea. Mediastinitis was suspected and treated intravenously with cefotaxime, amikacin, and high-dose penicillin G. The first chest X-ray at 24 ...