Mesenteric Air Embolism Following Enteroscopic Small Bowel Tattooing Procedure
A 76-year-old female presented to the emergency department with acute abdominal pain and multiple episodes of melena. Initial laboratory workup revealed a guaiac positive stool test and hemoglobin of 6-7 g/dL. Upper and lower endoscopies were negative and capsule endoscopy revealed inconclusive results. A subsequent DBE showed a 3 cm ulcerated lesion in the mid-ileum and a mesenteric mass in the distal small bowel.\nThe location of the small bowel mass was subsequently marked with mucosal clips and the bowel was enteroscopically tattooed up to the serosal surface with India ink for intraoperative localization for the laparoscopic surgical team. Three hours following the DBE, the patient complained of severe abdominal pain. Concern for bowel perforation was raised and a contrast-enhanced computed tomography (CT) scan of the abdomen and pelvis was ordered. The scan revealed a moderate amount of linear air tracking from the distal small bowel into the adjacent bowel venules and larger mesenteric veins. There was associated haziness surrounding the tumor location consistent with postprocedural edema [Figures , and ]\nThe presence of air in the mesenteric veins could not be attributed to disease pathology based on patient's clinical status and imaging. CT findings were correlated with location of enteroscopic tattoo and this led to the conclusion that bowel alterations from the tattoo procedure ultimately allowed for embolism of intraluminal bowel air into the adjacent mesenteric venous system. Due to this benign iatrogenic etiology of mesenteric venous gas, the patient's symptoms were managed conservatively and improved in a few hours. The patient subsequently underwent a successful laparoscopic small bowel resection for the mesenteric mass, which was confirmed by pathological examination to be a 4.5 × 2.5 × 2.5 cm gastrointestinal stromal tumor (GIST).