Pneumobilia vs portal vein gas

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Pneumobilia vs portal vein gas

  1. 1. PNEUMOBILIA VS PORTAL VEIN GAS
  2. 2. NORMAL ANATOMY  BILIARY SYSTEM
  3. 3. PORTAL SYSTEM
  4. 4. PNEUMOBILIA  Pneumobilia, also known as aerobilia, is accumulation of air in the biliary tree.
  5. 5. CAUSES Recent biliary instrumentation  ERCP  Percutaneous or intraoperative cholangiography
  6. 6. Incompetent sphincter of Oddi  Sphincterotomy (~ 50% have pneumobilia at 1 year)  Following passage of a gallstone  Scarring e.g. chronic pancreatitis  Drugs e.g. Atropine  Congenital(small amount of air only)
  7. 7. Biliary-enteric surgical anastomosis  Cholecystoenterostomy  Choledochoduodenostomy (with or without bile sump syndrome)  Whipple procedure
  8. 8. Spontaneous biliary-enteric fistula (cholecystoduodenal accounts for ~70% )  Gallstone ileus/ Bouveret's Syndrome  Peptic ulcer disease  Traumatic procedure  Neoplasm, eg. cholangiocarcinoma, ampullary cancer
  9. 9. Infection (rare)  Cholangitis  Emphysematous cholecystitis (usually gallbladder gas only, ~20% will have air in biliary tree also)  Liver abscess (if contains gas and communicates with biliary tree) Bronchopleuralbiliary fistula (rare)
  10. 10. EMPHYSEMATOUS GB CAUSES  All the causes of pneumobilia  Emphysematous cholecystitis >Gas forming organisms >Diabetes in 20% cases _ Pneumobilia present in 20% cases only _ Erect Xray Abdomen may show air-bile interface.
  11. 11. RIGLER’S TRIAD A triad of these findings in gall stone ileus:  Pneumobilia  Small bowel obstruction  Gall stone in right iliac fossa
  12. 12. RADIOGRAPHIC FEATURES  Linear branching air within the liver most prominent in central large caliber ducts
  13. 13. PLAIN FILM  Saber sign > Supine radiographs __ sword-shaped lucency in the right paraspinal region representing gas from the common bile duct and the left hepatic duct. >Present in ~ 50% of patients with pneumobilia.
  14. 14. ULTRASOUND  Very sensitive in detecting gas within the liver  Regions of high echogenicity with prominent shadowing or reverberation.  Gas moves with change in patient’s position  Liver has a 'striped appearance'.  Multiple “comet tail” artifacts
  15. 15. Pseudopneumobilia Produced by periductal fat that normally surrounds & parallels major biliary channels.  Continuous with extraperitoneal fat surrounding liver  Wider than non-obstructed biliary channels  Less radiolucent than gas in biliary ducts  Doesn’t involve intrahepatic portion of biliary tree
  16. 16. CT  Branching air-density regions within the liver.  Gas within the biliary tree tends to be more central.  Biliary gas is ante-dependent.  Typically fills the left lobe of the liver.
  17. 17. S
  18. 18. DIFFERENTIAL DIAGNOSIS Portal venous gas  Patients usually very ill (e.g. ischemic 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
  19. 19. PORTAL VENOUS GAS The accumulation of gas in the portal vein and its branches. Gas shadows extend to within 2 cm of liver capsule. Might be present in portal and mesenteric veins and bowel wall.
  20. 20. PATHOPHYSIOLOGY Some combination of  Bowel distension  Damage to mucosa  Intra-abdominal sepsis
  21. 21. Mesenteric artery Mechanical Occlusion obstruction. Bowel wall necrosis penetration of gas into vessel wall intrahepatic portal venous gas Infection of bowel wall Bowel wall necrosis penetration of gas into vessel wall portal venous gas
  22. 22. CAUSES Child  Umbilical vein catheterisation  Necrotising enterocolitis (NEC)  Neonatal gastroenteritis  Erythroblastosis fetalis  Postoperative finding in corrective bowel surgery
  23. 23. Adult Alterations of bowel wall  Ischaemic bowel (usually mural gas as well as mesenteric gas : mortality of 75 - 90% : but gas is not an independent predictor)  Necrotic / ulcerated colorectal carcinoma (CRC)  Inflammatory bowel disease (IBD)  Perforated peptic ulcer
  24. 24. Bowel luminal distention  Iatrogenic gastric and bowel dilatation (e.g upper and lower endoscopic procedures, enemas)  Paralytic ileus / mechanical obstruction  Acute gastric dilatation (in bed ridden young people. Recovery following decompression with NG tube)  Barotrauma
  25. 25. Intra-abdominal sepsis  Diverticulitis  Pelvic abscess  Cholecystitis and cholangitis  Appendicitis  Pancreatitis
  26. 26. Unknown mechanism  Pneumatosis intestinalis (primary)  Chronic obstructive pulmonary disease (COPD)  Corticosteroid usage  Pneumonia
  27. 27. CLINICAL FINDINGS  Will depend on the cause!
  28. 28. IMAGING FINDINGS  Can be diagnosed on conventional radiography, CT or ultrasound  Branching, air-containing structures near or at the periphery of the liver _from centrifugal flow of blood in portal vein  More air accumulates in left portal vein as it is more anterior, but air is seen more easily on plain films in right lobe of liver
  29. 29.  Thinner lucencies than air in branches of biliary tree (pneumobilia)
  30. 30. PLAIN X-RAY ABDOMEN
  31. 31. ULTRASOUND  Ultrasound shows bright, echogenic foci in the periphery of the liver with centrifugal flow.
  32. 32. CT  Branching pattern of gas, distributed periphraly, reaching upto 2 cm of liver capsule
  33. 33. DIFFERENTIAL DIAGNOSIS  Pneumobilia
  34. 34. TREATMENT  Surgery __for ischemic bowel disease, especially for those with signs of perforation, sepsis or peritonitis.
  35. 35. PROGNOSIS  With bowel necrosis, mortality remains high (45- 65%)  Without bowel necrosis, may spontaneously and quickly resolve without significant mortality.
  36. 36. PNEUMOBILIA VS PORTAL VENOUS GAS
  37. 37. A SIMPLE MNEMONIC  Portal venous gas = Peripheral  Common bile duct gas = Central
  38. 38. FEW CASES

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