Cardiogenic unilateral pulmonary edema: an unreported complication of a digestive endoscopic procedure

doi: 10.1111/j.1751-7133.2009.00102.x
CASE REPORT
Cardiogenic Unilateral Pulmonary Edema: An Unreported
Complication of a Digestive Endoscopic Procedure
E
ndoscopic procedures of the gut
have a low rate of complications,
and some of them are life-threatening.
Unilateral pulmonary edema (UPE) is
an uncommon entity that can be mistaken for other causes of alveolar and
interstitial infiltrates. Cardiogenic unilateral edema mostly affects the right
lung. There are no reports in the literature about UPE as a complication of an
endoscopic procedure of the gastrointestinal tract.
Case Report
Anemia developed in a 79-year-old
woman with a history of arterial hypertension and chronic atrial fibrillation. In
the study of the cause of anemia, a diagnostic upper and lower digestive endoscopy was performed. Immediately after
the procedure, she experienced chills,
dyspnea, and cyanosis. Her blood pressure was 210 ⁄ 110 mm Hg, heart rate
was 120 beats ⁄ min, respiratory rate was
30 breaths ⁄ min, axillary temperature
was 36.6C, and oxygen saturation was
80% on room air. Auscultation revealed
diminished breath sounds and crackles
over the lower two thirds of the
left lung. Electrocardiography (ECG)
showed subendocardial ischemia in the
anterior wall, and chest radiography
showed unilateral alveolar-interstitial
infiltrates in the left lung (Figure 1).
Laboratory tests revealed a hemoglobin
A1c level of 11 g ⁄ dL, white blood cell
count of 12,400 ⁄ uL, creatinine level of
1 mg ⁄ dL, urea level of 59 mg ⁄ dL, and
troponin I level of 0.6 ng ⁄ dL (normal
value, <0.01 ng ⁄ dL). Echocardiography
showed a left ventricular ejection fraction of 70%, left atrium enlargement,
septum hypertrophy, and impaired relaxation of the left ventricle. The patient
was treated with noninvasive ventilatory
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cardiogenic UPE
Unilateral pulmonary edema is an uncommon clinical situation that may be difficult to distinguish from other conditions that cause lung infiltrates. Most cases occur in the right
lung, and there are no reports about cardiogenic unilateral pulmonary edema as a complication of an endoscopic procedure of gastrointestinal tract. The authors describe a case
of a 79-year-old woman with acute cardiac heart failure that developed soon after a
diagnostic upper and lower digestive endoscopy. Continuous positive airway pressure,
intravenous nitroglycerin, and furosemide treatment resulted in rapid improvement of
symptoms and the progressive resolution of left-sided infiltrates on chest radiography. This
case is of particular importance because of the rarity of cardiogenic unilateral edema in
the left lung. This clinical finding was associated with the prolonged rest on the left side
during the gastrointestinal endoscopic procedure. Congest Heart Fail. 2009;15:
252–253. 2009 Wiley Periodicals, Inc.
Enrique M. Baldessari, MD;1 Andres Mendez-Villarroel, MD;1
Eduardo Mauriño, MD;2 Fabio D. Nachman, MD;2 Ignacio A Veltri, MD1
From the Department of Internal Medicine1 and Gastroenterology Section,
2
Favaloro Foundation University Hospital, Buenos Aires, Argentina
Address for correspondence:
Enrique M. Baldessari, MD, Department of Internal Medicine, Favaloro
Foundation University Hospital, Solis 461 (C1078AAI), Buenos Aires, Argentina
E-mail: [email protected]
Manuscript received January 9, 2009; revised May 29, 2009;
accepted May 29, 2009
support with continuous positive airway
pressure (CPAP) and intravenous nitroglycerin and furosemide. Cultures were
performed on blood and urine. After
24 hours of treatment, symptoms dramatically improved, ECG revealed no
alterations of ST segment, and repeated
chest radiography showed resolution of
the infiltrates (Figure 2). Microbiological
test results were negative.
Discussion
Pulmonary edema develops as a consequence of an imbalance of Starling’s law
or is secondary to the disruption of the
alveolar capillary membrane. As a rule,
in cardiac failure it affects both lungs.
UPE is an uncommon disorder with
several reported causes (Table).1 In this
report, the patient presented with dia-
Figure 1. Chest radiography performed on
admission showed alveolar-interstitial infiltrates limited to the left lung.
stolic heart failure with left UPE, triggered by a hypertensive emergency with
a subendocardial infarct that developed immediately after gastrointestinal
september october 2009
•
Figure 2. Chest radiography performed after 24 hours (A) and after 48 hours (B) of treatment showed a progressive clearing of the opacities
on the left side.
endoscopy. That the left lung infiltrates
were cardiogenic is supported by their
rapid clearing after diuretic therapy.
Most cases of UPE associated with
left heart failure affect the right lung.2
A possible explanation is the inferior
lymphatic drainage of the right lung
by the small-caliber right bronchomediastinal trunk in comparison to the
large-caliber thoracic duct in the left
lung.3 In patients with mitral regurgitation, the mechanism of right UPE is
related to the retrograde flow in the
right pulmonary veins during ventricular systole.4–6
The left cardiogenic UPE in this case
would be in relation to the left lateral
decubitus position adopted by the
patient while the procedure was performed in the context of cardiac
decompensation.
Gravity raises the hydrostatic pressure in the dependent lung, impairing
circulation and affecting the produc-
tion of surfactant. The lateral decubitus position could compromise lung
mechanisms. There is relative hyperperfusion and hypoventilation of the
dependent lobes, and when volume
overload or heart failure exists, it
could result in pulmonary edema of
the dependent lung.7 This situation
usually develops in patients placed in
the lateral decubitus position for a
prolonged period. Case reports of left
UPE were described in mechanical
ventilation patients with left decubitus
to promote bronchial drainage, in
immobilized individuals because of
neurologic deficits, and during transesophageal echocardiography.8
Conclusions
Table. Reported Causes of Unilateral
Pulmonary Edema
Congestive heart failure
Acute mitral valve regurgitation
Reexpansion after pleurocentesis
Prolonged rest on one side (plus cardiac
failure or large aumonts of fluids)
Chest trauma
After talc pleurodesis
Epilepsy
Upper-airway obstruction
Unilateral main stem intubation
Neurogenic pulmonary edema
Nitrogen mustard use
Amiodarone-related and heroin-related
pulmonary edema
Pregnancy
Pulmonary venous obstruction (mediastinal
fibrosis or postlobectomy)
Pulmonary artery compression from aortic
dissection
Unilateral pulmonary agenesis
UPE due to left heart failure is a distinctly uncommon condition. This case
is of particular importance because of
the rarity of cardiogenic unilateral
edema in the left lung. These clinical
findings were associated with prolonged
rest on the left side during the gastrointestinal endoscopic procedure.
4
7
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