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 this 55-year-old male has a history of intermittent vomiting; his status is post-cholecystectomy  C'est un patient âgé de 55 ans avec une histoire de vomissements intermittents; il a eu avant une cholécystectomie.

* Scan 1 : Long-axis view of an intrahepatic duct shows a bright linear shadowing focus. Note the 'reverberative' shadow (ring-down artifacts) indicating that the echogenic material is definitely gas.
* Scan 2 : Cause: Biliary-duodenum fistula.
* Scan 3 &4 : highly reflective linear echoes with multiple discrete bubbles in the duct and faint shadowing. These bubbles were mobile on real time.
*Cliché 1 : Coupe sagittale des voies biliaires montrant des foyers linéaires échogènes avec ombres. Notez les ondes réverbératives d'ombres postérieurs (ring-down artifacts) indiquant que le matériel échogène est de l'air.
* Cliché 2 : Cause : fistule bilio- duodénale.
* Cliché 3 et 4 : Echos linéaires très brillants avec multiples petites bulles dans les conduits avec cone d'ombre postérieur mal définie. En temps réel, ces bulles gazeuses sont mobiles.



Pneumobilia with Biliary-duodenum fistula
Aérobilie acvec fistule bilio-duodénale



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Pneumobilia is the presence of air within the biliary tree. Air in the biliary tree is usually iatrogenic and is frequently seen following procedures such as ERCP, sphincterotomy or biliary surgery but may also occur after the passage of gallstones or distortion of the lower common bile duct by local inflammation, tumor or duodenal ulceration. Although it does not usually persist, the air can remain in the biliary tree for months or even years and is not significant.

Ultrasonography :
Air within the bile ducts is seen as densely echogenic lines with shadowing along the course of the biliary system. It is characterized by highly reflective linear echoes, which follow the course of the biliary ducts. The air usually casts a shadow which is different from that of stones, often having reverberative artifacts 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.
Intrabiliary gas is occasionally indistinguishable from stones. In most cases gas produces a brighter reflection and dirtier shadow than do stones. A ring-down artifact is only seen behind gas and, when found, can be used to confirm the diagnosis of pneumobilia. Gas is also more likely to move.

* Portal venous : air In pneumobilia the air is not carried peripherally to the same extent as portal venous gas. The most difficult distinction lies between air within the biliary tract and air within the portal system. They represent two entirely different clinical entities. Pneumobilia is associated with biliary-enteric fistula, incompetent sphincter of Oddi, and emphysematous cholecystitis, and is commonly seen following biliary bypass operations. The finding of portal venous air requires urgent surgical exploration. The list of causes of portal venous gas is long, but ischemic bowel with infarction and necrosis is by far the most common etiology and carries a grave prognosis.
* stone : A similar pattern of echogenic liver foci may be produced by calcifications. Calcifications within the liver generally produce clearly definable acoustic shadows, even with low-frequency transducers. Rarely, multiple biliary stones form within the ducts throughout the liver and can be confused with the appearances of air in the ducts. Finally, gas within the biliary radicles often appears as linear echogenic foci. This appearance is less common with calcifications. Gas is also more likely to move.

Causes of Pneumobilia :
* Following ERCP (endoscopic retrograde cholangiopancreatographiy).
* Sphincterotomy.
* Following surgery - biliary-enteric anastamosis.
* Biliary fistula: gastric or duodenal ulcer, gastric or colonic carcinoma, bile duct carcinoma, gallstone ileus, following cholecystectomy, carcinoma gallbladder, Crohn's disease.
* Abdominal trauma.
* Ruptured duodenal diverticulum's.
* Emphysematous cholecystitis.
* Cholangitis.
* Patulous ampulla.
* Rupture of hydatid cyst into the bile ducts.
* Hepatobiliary ascariasis.
* Tracheobiliary fistula (congenital anomaly presenting with respiratory distress in the newborn).
* Effect of drugs on the sphincter (magnesium, atropine, nitroglycerine and dopamine).


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