Ultrasound images of Pneumobilia

Air in the biliary tree is usually iatrogenic and is frequently seen following procedures such as ERCP, sphincterotomy or biliary surgery. Although it does not usually persist, the air can remain in the biliary tree for months or even years and is not significant. It is characterized by highly reflective linear echoes (Fig. A), which follow the course of the biliary ducts. The air usually casts a shadow which is different from that of stones, often having reverberative artefacts and being much less well-defined or clear. This shadowing obscures the lumen of the duct and can make evaluation of the hepatic parenchyma difficult. Pneumobilia may also be present in emphysematous cholecystitis, an uncommon complication of cholecystitis in which gas-forming bacteria are present in the gallbladder (see above), or in cases where a necrotic gallbladder has formed a cholecystoenteric fistula.

FIG A. Air in the biliary tree following surgery.
Note the ‘reverberative’ shadow

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