Pneumobilia, also known as aerobilia, is the accumulation of gas in the biliary tree. It is important to distinguish pneumobilia from portal venous gas, the other type of branching hepatic gas. There are many causes of pneumobilia and clinical context is often important to distinguish between these 3.
- recent biliary instrumentation
- percutaneous or intraoperative cholangiography (small amount of gas only)
- incompetent sphincter of Oddi
- sphincterotomy (~50% pneumobilia at 1 year)
- following passage of a gallstone
- scarring e.g. chronic pancreatitis
- drugs e.g. atropine
- biliary-enteric surgical anastomosis
- spontaneous biliary-enteric fistula (cholecystoduodenal accounts for ~70% 3)
- infection (rare)
- biliary-bronchopleural fistula (rare)
Pneumobilia is typically seen as linear branching gas within the liver most prominent in central large calibre ducts as the flow of bile pushes gas toward the hilum. This is in contrast to portal venous gas where peripheral small calibre branching gas is usually seen due to the hepatopetal flow of blood away from the hilum.
Supine radiographs often demonstrate a sword-shaped lucency in the right paraspinal region representing gas from the common duct and the left hepatic duct. This has been termed the sabre sign and is present in ~50% of patients with pneumobilia 4.
Ultrasound is very sensitive in detecting gas within the liver as it causes artifact, specifically regions of high echogenicity with prominent shadowing or reverberation. The liver has been described as having a 'striped appearance'.
Branching hepatic gas is easily appreciable on CT as branching gas-density regions within the liver.
Differentiating between biliary and portal venous gas is usually achievable especially when intravenous contrast is used. Gas within the biliary tree tends to be more central, whereas gas within the portal venous system tends to be peripheral (carried along by the blood). Also, biliary gas is antidependent, and typically fills the left lobe of the liver.
The differential of pneumobilia is very limited:
portal venous gas
- patients usually ill (e.g. ischaemic bowel)
- gas more peripheral in liver
- Doppler imaging may help
- hepatic artery calcification (on ultrasound)
- often seen in those with chronic renal failure
- mimic pneumobilia on ultrasound 5
More importantly every attempt should be made at assessing the cause of pneumobilia, as a number of causative entities require prompt management.
- 1. Dähnert W. Radiology review manual. Lippincott Williams & Wilkins. (2003) ISBN:0781738954. Read it at Google Books - Find it at Amazon
- 2. Hawes DR, Pelsang RE, Janda RC et-al. Imaging of the biliary sump syndrome. AJR Am J Roentgenol. 1992;158 (2): 315-9. AJR Am J Roentgenol (abstract) - Pubmed citation
- 3. Sherman SC, Tran H. Pneumobilia: benign or life-threatening. J Emerg Med. 2006;30 (2): 147-53. doi:10.1016/j.jemermed.2005.05.016 - Pubmed citation
- 4. Lewandowski BJ, Withers C, Winsberg F. The air-filled left hepatic duct: the saber sign as an aid to the radiographic diagnosis of pneumobilia. Radiology. 1984;153 (2): 329-32. Radiology (abstract) - Pubmed citation
- 5. Pai SS, Bude RO. Sonographic appearance of extensive hepatic arterial calcification mimicking pneumobilia. J Clin Ultrasound. 2002;30 (1): 38-41. J Clin Ultrasound (link) - Pubmed citation