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Case Reports
. 2014 Oct 13:2014:bcr2014206798.
doi: 10.1136/bcr-2014-206798.

Choledochoduodenal fistula: an unusual case of pneumobilia

Raphael Fedidat  1 , Wajdi Safadi  2 , Igor Waksman  1 , Amram Hadary  1
Affiliations
Case Reports

Choledochoduodenal fistula: an unusual case of pneumobilia

Raphael Fedidat et al. BMJ Case Rep. .

Abstract

Pneumobilia is the finding of air in the biliary tree. Most cases are iatrogenic in origin, especially after sphincterotomy and after hepaticojejunostomy or choledochojejunostomy. In patients without such history, the presence of pneumobilia needs further investigation. Most patients are likely to have an enterobiliary fistula. Although patients may be asymptomatic, possible complications include gallstone ileus, Bouveret syndrome or recurrent episodes of cholangitis. We present a case of a 38-year-old man presenting with obstructive jaundice and pneumobilia in whom choledochoduodenal fistula was diagnosed at endoscopic retrograde cholangiography. A description of different types of choledochoduodenal fistulas and management recommendations are also provided.

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Figures

Figure 1
Figure 1
Plain abdominal X-ray showing air in biliary tree (white arrow).
Figure 2
Figure 2
CT showing gallbladder with wall thickening (white arrow) and enlarged common bile duct with sludge (black arrow).
Figure 3
Figure 3
CT showing air within intrahepatic bile ducts (white arrows).
Figure 4
Figure 4
Barium swallow test demonstrating reflux of contrast into the common bile duct. Adapted from Hoppenstein et al.
Figure 5
Figure 5
Gastroduodenoscopy showing ostium with bilious secretion entering through the posterior wall of the duodenal bulb. Adapted from Neumann et al.
Figure 6
Figure 6
Endoscopic repair of a proximal choledochoduodenal fistula with an 11 mm over-the-scope clip. Adapted from Neumann et al.
Figure 7
Figure 7
Ikeda classification of distal choledochoduodenal fistula. CBD, common bile duct; MPD, main pancreatic duct; P, papilla of vater; F, fistula.
Figure 8
Figure 8
Photographs from endoscopic retrograde cholangiopancreatogram. (A) The ampulla of Vater with cannula in place. Contrast injected through the cannula flows back into the duodenum through the fistula tract. (B) After papillotomy, two large common bile duct stones being extracted into the duodenum using the papillotomy. Adapted from http://www.EndoAtlas.com, Atlanta South Gastroenterology.
See this image and copyright information in PMC

References

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