The case reported is that of a 10-year-old girl born with congenital biliary atresia
who had undergone a Kasai procedure in the first year of life. She presented with
ascending cholangitis, and investigations revealed a stricture of her portoenterostomy
with an intrahepatic stone above the stricture. At laparotomy there were numerous
adhesions and dilated varices, so the descending loop of the Kasai was exteriorized
to enable a subsequent percutaneous endoscopic manipulation of the stone. During manipulation
of the stricture via a pediatric endoscope in the jejunal loop the patient collapsed
and died. Post mortem revealed a massive air embolism and varices of the jejunal loop.
Biliary system - Endoscopy - Air embolism
