United Health Services Johnson City, NY, United States
Fahad Malik, MD1, Mohammad A. Abidi, MD1, Ali Khan, MD2, Godson D. Senyondo, MD2, Atif Saleem, MD1, Amanke Oranu, MD2 1United Health Services, Johnson City, NY; 2UHS Wilson Hospital, Johnson City, NY
Introduction: Pneumobilia is defined by air within the biliary system caused by an abnormal connection between the gastrobiliary tracts. Hepatic portal vein gas and pneumobilia due to abdominal trauma are extremely rare CT findings. Common etiologies are emphysematous cholecystitis, ascending cholangitis or from surgical instrumentation (ERCP). We present an extremely rare case of a 27-year-old with no past medical or surgical history who presented with epigastric tenderness found to have benign chronic pneumobilia of 12 years.
Case Description/Methods: 27-year-old female past medical history of chronic neck and back pain due to a motor vehicle accident in 2009 presented to the emergency room with epigastric and right upper quadrant abdominal pain of 3 weeks associated with loss of appetite, nausea and vomiting. She also has a longstanding history of chronic neck and back pain for which she used NSAIDs and chronic medical marijuana for relief.
Patient labs were all within normal range, including liver function tests. CT of her abdomen and pelvis showed an incidental finding with tiny scattered gas bubbles within the liver which could represent pneumobilia concerning for ascending cholangitis or portal venous gas. She had no recent trauma, history of abdominal surgeries or instrumentations. Therefore, she was started on broad spectrum antibiotic coverage. Her physical examination was completely benign with soft abdomen, nondistended with mild right upper quadrant pain. On reviewing all of her prior imaging, pneumobilia was found on all CT scans obtained from 2009 to 2021. She underwent an upper endoscopy which showed normal papilla and duodenum but erythematous gastritis likely from her NSAIDs use and improved with pantoprazole 40mg twice a day.
Discussion: Pneumobilia or Intra-biliary air can range from a completely incidental to a life-threatening finding on CT imaging. Findings of air within the portal venous system can indicate bowel ischemia, gas gangrene, pyogenic liver abscess, cholangitis, sphincter of oddi dysfunction, or small bowel infection. Chronic traumatic pneumobilia of 12 years is an extremely uncommon finding and should be used as a diagnosis of exclusion. In addition, radiological imaging should always be used in clinical correlation to provide appropriate care for the patient. The patient above did well on proton pump inhibitor with resolution of all her abdominal symptoms in 48 hours and she was discharged.
Figure: CT Abdomen Pelvis 2009 & 2020
Fahad Malik indicated no relevant financial relationships.
Mohammad Abidi indicated no relevant financial relationships.
Ali Khan indicated no relevant financial relationships.
Godson Senyondo indicated no relevant financial relationships.
Atif Saleem indicated no relevant financial relationships.
Amanke Oranu indicated no relevant financial relationships.
Fahad Malik, MD1, Mohammad A. Abidi, MD1, Ali Khan, MD2, Godson D. Senyondo, MD2, Atif Saleem, MD1, Amanke Oranu, MD2. P0784 - Case of a Traumatic Chronic Pneumobilia, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.