J Ped Surg Case Reports 3 (2015) 496e498

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Journal of Pediatric Surgery CASE REPORTS

journal homepage: www.jpscasereports.com

A rare case of pneumobilia with pneumoperitoneum following

paediatric blunt abdominal trauma
Mohan Marulaiah a, *, B.M. Harsha a, S. Swaroop b
a
Department of Paediatric Surgery, JJM Medical College, Davangere 577004, Karnataka, India
b
Department of General Surgery, JJM Medical College, Davangere 577004, Karnataka, India

a r t i c l e i n f o a b s t r a c t

Article history: Pneumobilia and pneumoperitoneum are two uncommon findings following blunt trauma abdomen.
Received 4 December 2014 Existing literature identifies seven cases of traumatic Pneumobilia reported in adults, out of which only
Received in revised form one had coexisting pneumoperitoneum. We report the first case of paediatric pneumobilia with coex-
13 May 2015
isting pneumoperitoneum, following blunt abdominal trauma, which was managed conservatively.
Accepted 18 May 2015
Ó 2015 The Authors. Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND
license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Key words:
Blunt trauma
Pneumobilia
Pneumoperitoneum
Paediatric

Pneumobilia and pneumoperitoneum are two uncommon The patient was hemodynamically stable and clinically improved
findings following blunt trauma abdomen. On reviewing the liter- with time, conservative management was continued. After 48 h
ature, seven cases of pneumobilia in the setting of blunt abdominal patient bowel function returned to normal and oral feeds was
injury have been reported. We report the first case of paediatric
pneumobilia with pneumoperitoneum, following blunt abdominal
trauma, which was managed conservatively.

1. Case report

A 6 year old male child sustained blunt abdominal trauma,

sustained from the knee of a pillion rider on motorcycle, when he
was walking on the road. The patient was referred 5 h after the
injury, with vomiting and abdominal pain. The patient was
conscious, oriented and haemodynamically stable.
Clinical examination revealed no external injuries, but he had
tenderness in the upper and right side of the abdomen. Appropriate
resuscitation was initiated. Emergency ultrasonography showed
minimal hemoperitoneum. Chest X ray and erect X ray abdomen
were normal. On CT with oral and IV contrast, patient was found to
be having pneumobilia, small pneumoperitoneum and grade 1
hepatic injury of the 4A segment of right lobe of liver and fracture
anterior aspect of 7, 8, 9 ribs on right side as shown in Figs. 1 and 2.
There was no pneumothorax e Fig. 3.

* Corresponding author. 3985, Vidyanagar, Davangere, Karnataka 577005, India.

Tel.: þ91 8762782664.
E-mail address: mohanm@outlook.com (M. Marulaiah). Fig. 1. CT scan showing pneumobilia (arrow A) and pneumoperitoneum (arrow B).

2213-5766/Ó 2015 The Authors. Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
http://dx.doi.org/10.1016/j.epsc.2015.05.009
 M. Marulaiah et al. / J Ped Surg Case Reports 3 (2015) 496e498 497

Fig. 2. CT scanecoronal section showing pneumobilia (arrow).

initiated. The patient was discharged on 6th day. On follow up at 4
weeks and 12 weeks there were no clinical symptoms. No further
investigations were performed.
2. Discussion
Pneumobilia is uncommon in trauma but can be seen in other
pathologies. Pressures in a normal biliary tree may be as high as
30 cm H2O when the gallbladder contracts. This is comparable to
the 35 cm H2O baseline pressure in the duodenal lumen. The
sphincter of Oddi is capable of exerting a resistance of up to
60 cm H2O. The transfer of an extrinsic pressure greater than
60 cm H2O to the duodenal lumen may cause retrograde air flow
into the biliary tree [1]. Hence, blunt abdominal injury could be the
cause of pneumobilia by this mechanism.
In the setting of blunt abdominal trauma pneumoperitoneum
does not necessarily indicate hollow viscus injury. With increasing
sensitivity of present CT scans, pneumoperitoneum is detected
more often in blunt trauma. CT detected pneumoperitoneum is not
always pathognomonic of hollow viscus injury. It frequently is
Fig. 3. CT scan of lower thorax (lung windows) e no pneumothorax.
secondary to other aetiologies, especially dissection of interstitial
air from the chest [2,3]. Pneumoperitoneum is likely to be due to
blunt chest injury in our patient.
On reviewing the literature, seven cases of pneumobilia in the
setting of blunt abdominal injury have been reported (Table 1).
Pneumobilia has been historically associated with diseases that
mandate surgical intervention. None of the seven cases reported in
the literature have had pneumobilia with an aetiology that could have
mandated surgery. The authors that reported these cases attribute
the pneumobilia to retrograde passage of air through the sphincter of
Oddi into the biliary tract. This thought was originally entertained
when Bautista et al. reported the case of a patient with a proximal
small bowel obstruction and incidental pneumobilia. When a naso-
gastric tube was placed, 5 L of pressurized fluid was drained. This
finding suggested that the high pressure being imparted by the fluid
inside the upper gastrointestinal tract caused retrograde flow of air
through the sphincter of Oddi into the biliary system [9].

Table 1
Overview of cases of pneumobilia reported in literature.

Authors Age of the Additional findings in CT Interventions e findings Outcome

patient
1 Barnes et al. [4] 47 years Splenic laceration Exploratory laparotomyeminimal hemoperitoneum Discharged
2 Barnes et al. [4] 34 years Grade 1 hepatic laceration, Upper gastrointestinal endoscopyenone Discharged
minimal free fluid, intestinal
dilation
3 Barnes et al. [4] 45 years None None Discharged
4 Gering et al. [5] 89 years Duodenal contusion, scant Exploratory laparotomyenone Deatha
pneumoperitoneum
5 Thompson et al. [6] 19 years None None Discharged
6 Zequeira et al. [7] 71years Duodenal contusion, L2 & L3 None Discharged
transverse process fracture,
minimal free fluid
7 Huang et al. [8] 65 years CBDb dilation None Discharged
8 Present case report 6 years Grade 1 hepatic laceration, None Discharged
minimal free fluid, scant
pneumoperitoneum, fracture
of 7, 8, 9 ribs on right side
a
Death due to Acute Respiratory Distress Syndrome, Multiple Organ Dysfunction Syndrome.
b
Common bile duct.
498 M. Marulaiah et al. / J Ped Surg Case Reports 3 (2015) 496e498
Ladurner et al. reported another case that supports the concept
of pneumobilia induced by a sudden increase in intrabdominal
pressure. They reported the case of a patient who developed
pneumobilia after cardiopulmonary resuscitation. They attributed
this finding to the transmission of increased intrathoracic pressure
to the abdominal cavity [10]. There have been other non-trauma
related cases in which the incidental pneumobilia was attributed to
sphincter incompetence [11e13].
3. Conclusion
Pneumobilia and pneumoperitoneum is very rare in paediatric
blunt trauma. They have, historically, been associated with diseases
which mandate surgical intervention. Of the seven adult cases re-
ported earlier with pneumobilia, only two cases were managed
operatively, but on exploration surgically correctable cause of
pneumobilia was not found. Pneumoperitoneum on its own, has
been an indication for exploration in blunt trauma abdomen. With
increasing sensitivity of present CT scanners there will be increased
detection and incidence of pneumobilia and pneumoperitoneum,
some of which can be managed conservatively. This may be even
more relevant in paediatric cases, as isolated blunt abdominal
injury is more common in this age group.
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