Pneumobilia

Pneumobilia is the presence of gas in the biliary system. It is typically detected on a radiographic imaging exam, such as ultrasound, CT, or MRI. It is a common finding in patients that have recently undergone biliary surgery or endoscopic biliary procedure. While the presence of air within biliary system is not harmful, this finding may alternatively suggest a pathological process, such as a biliary-enteric anastomosis, an infection of the biliary system, an incompetent sphincter of Oddi, or spontaneous biliary-enteric fistula.

Causes

In a healthy individual with normal anatomy, there is no air within the biliary tree. When this finding is present, it may be secondary to:

Other rare causes that have been reported include duodenal diverticulum, paraduodenal abscess, operative trauma, and carcinoma of the duodenum, stomach and bile duct.[1][2]

Diagnosis

Intravenous cholangiography, endoscopic retrograde cannulation of the common bile duct and endoscopy can be used to visualize such a fistulous communication but there are no reports in literature describing the use of these techniques. Also barium studies can be used to demonstrate such a fistulous communication but the appearances should be distinguished from reflux of barium through the ampulla of Vater. In case of reflux the common bile duct fills only in its distal portion, whereas there is usually filling of the intrahepatic ducts in choledochoduodenal fistula. Another radiological finding that can be seen in such biliary enteric fistulas is pneumobilia which is the presence of air in the biliary tree.

Management

Treatment of choledochoduodenal fistula secondary to duodenal ulcer stands divided between prophylactic surgery and conservative medical therapy. Experience from our case favors the latter but it also depends on the case presentation. There have been reports of worsening of biliary disease with non surgical management of choledochoduodenal fistula but in the absence of primary biliary disease, a choledochoduodenal fistula created by perforating duodenal ulcer presents a minimal risk of cholangitis or future biliary stricture, although the potential must at least be acknowledged. Indeed, Waggoner, LeMone and others report closure of a choledochoduodenal fistula with medical management. For such reasons Jordan and Stirrett [[3]], and later Isaacson et al. [[4]], were the first to actively suggest intensive medical management, especially in asymptomatic or poor risk patients. Evidence towards intensive medical management has grown over the past decades. A case series by Constant and Turcotte demonstrated successful medical management of four cases for up to a period of 11 years. recent consensus acknowledges treatment of the ulcer disease itself as the major goal and suggests surgical intervention in high risk or asymptomatic patients only for the usual indications in peptic ulcer disease, that is, hemorrhage, obstruction or intractability.

Epidemiology

Typically, patients with choledochoduodenal fistulas are usually in the fifth or sixth decade of life and have a long history of symptomatic dyspepsia. While women comprise approximately 70 percent of all cases of internal biliary fistula secondary to gall- bladder disease,[5] men outnumber women by 3 to 1 or greater in biliary communications arising from penetrating duodenal ulcer. In 80%, the cause of choledochoduodenal fistula is usually penetrating duodenal ulcer disease in patients with a long ulcer history.[6]

References

  1. ↑ Marshall SF, Polk RC. Spontaneous internal biliary fistula. Surg Clin North Am 1958; 38:679.
  2. ↑ ReMine WH. Biliary-enteric fistulas: natural history and management. Adv Surg 1973;7:69.
  3. ↑ Jordan PH, Stirrett LA. Treatment of spontaneous internal biliary fistula caused by duodenal ulcer. Am J Surg 1956; 91:307
  4. ↑ Isaacson S, Appleby LW, Hamilton EL. Choledocho-duodenal fistula secondary to duodenal peptic ulcer. JAMA 1962: 179:969
  5. ↑ 3. Sarr MG, Shepard AJ, Zuidema GD: Choledochoduodenal fistula: An unusual complication of duodenal ulcer disease. Am J Surg 1981;141:736–740
  6. ↑ Lewis EA, Bohrer SP. Choledochoduodenalfistula complicating chronic duodenal ulcer in Nigerians. Gut 1969:10:146
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