Is PMCT volume rendering still up in the air, or the next key step in proving the cause of death in iatrogenic systemic air embolism?

Background Systemic air embolism is a rare but potentially fatal complication of invasive medical procedures, including endoscopic retrograde cholangiopancreatography (ERCP). Accurate post-mortem diagnosis is challenging, as conventional autopsy may fail to reveal the full extent and distribution of intravascular gas. Case Presentation We report a 65-year-old male with obstructive jaundice who underwent ERCP for stenting and tissue sampling of a suspected distal bile duct carcinoma. During the procedure, a sphincterotomy and guidewire-induced false tract allowed insufflated air to escape into the retroperitoneum and vasculature, resulting in cardiorespiratory collapse. Post-mortem computed tomography (PMCT) demonstrated abundant gas throughout the cardiac ventricles, retroperitoneum, and mesocolon. Volumetric rendering quantified the abnormal gas burden, providing objective radiological evidence supporting the diagnosis of fatal systemic air embolism. Autopsy corroborated the sphincterotomy defect, retroperitoneal air, and underlying cholangiocarcinoma. Discussion PMCT enables visualisation of abnormal gas distributions before organ manipulation, distinguishing pathological gas from post-mortem artefact. Volumetric rendering quantified the abnormal gas burden, providing objective radiological evidence supporting the diagnosis of fatal systemic air embolism. Conclusion This case highlights the pivotal role of PMCT with volumetric rendering in procedure-related deaths. By providing pre-dissection insight into gas distribution and volume, PMCT enhances the forensic evaluation of iatrogenic vascular air embolism, representing a critical step in establishing the cause of death.