Pneumobilia: Benign or life-threatening

doi:10.1016/j.jemermed.2005.05.016

The Journal of Emergency Medicine

Volume 30, Issue 2, February 2006, Pages 147-153

https://doi.org/10.1016/j.jemermed.2005.05.016 Get rights and content

Abstract

Pneumobilia, or air within the biliary tree of the liver, suggests an abnormal communication between the biliary tract and the intestines, or infection by gas-forming bacteria. Pneumobilia usually can be distinguished from air in the portal venous system by its appearance on computed tomography (CT) scan. The most common conditions associated with pneumobilia include: 1) a biliary-enteric surgical anastamosis, 2) an incompetent sphincter of Oddi, or 3) a spontaneous biliary-enteric fistula. Three cases of pneumobilia associated with its most common causes are presented and further differential diagnostic possibilities as well as the implications of this finding on patient management are discussed.

Introduction

Pneumobilia is defined as the presence of gas in the biliary tree of the liver. Its presence suggests an abnormal communication between the biliary tract and adjacent organs, commonly the gastrointestinal tract. Pneumobilia may reflect a benign incidental finding or herald a life-threatening disease state. The most common conditions associated with pneumobilia include: 1) a biliary-enteric surgical anastamosis, 2) an incompetent sphincter of Oddi, or 3) a spontaneous biliary-enteric fistula (1, 2, 3). We report three cases of pneumobilia associated with its most common causes and discuss further differential diagnostic possibilities as well as the implications of this finding on patient management. A waiver was obtained from the Institutional Review Board at our hospital.

Section snippets

Biliary-Enteric Anastamosis and Sump Syndrome

A 67-year-old woman presented to the Emergency Department (ED) with epigastric abdominal pain. The patient stated the pain had begun 5 h earlier. She described it as crampy in nature and severe. She had associated nausea, but no vomiting or diarrhea and had no prior history of similar pain. The past medical history was significant for peptic ulcer disease and a “gall bladder” surgery many years ago. Physical examination revealed an elderly woman in moderate abdominal distress. Vital signs were

Post-Sphincterotomy

A 40-year-old man presented with abdominal pain of 2 days duration. He stated the pain was constant, diffuse, and did not radiate. He had no previous history of similar pain. The patient reported multiple episodes of vomiting, but no diarrhea or fever. The past medical history was significant for Type II diabetes mellitus, a cholecystectomy, and an ERCP with sphincterotomy performed “years” ago for gallstones. He was noncompliant with his diabetes medications and could not remember the

Spontaneous Biliary-Enteric Fistula

A 60-year-old man presented with right upper quadrant and epigastric abdominal pain of 3 days duration. The pain was described as sharp, constant, and radiated to the back. The patient reported anorexia and nausea, but no vomiting or fevers. The patient had a history of Type II diabetes, gastroesophageal reflux, and peptic ulcer disease. He did not drink alcohol. Physical examination revealed an obese male in no acute distress. Vital signs revealed a temperature of 36.1°C (97.0 °F); blood

Discussion

When air is identified in the liver on CT scan, ultrasound or less commonly, plain abdominal radiographs, the first distinction that must be made is between biliary air and portal venous air (4). Both entities can be due to benign or life-threatening conditions, but the list of potential causes is different for each. For example, mesenteric ischemia accounts for approximately 50% of cases of portal venous air, but is not associated with pneumobilia (5). Although portal venous air is a late and

Conclusion

The presence of air in the biliary system may indicate either a benign or potentially life-threatening condition. The presence of pneumobilia requires a prompt search to rule out serious infectious etiologies. This is especially true in ill-appearing patients without an alternative iatrogenic explanation for their pneumobilia. Surgical and gastrointestinal consultation may be necessary and early antibiotics are appropriate in patients with fever or signs of sepsis. If pneumobilia seems to be an

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Clinical communicationPneumobilia: Benign or life-threatening