Pneumobilia: A Case Report and Literature Review on its Surgical Approaches
An 82-year-old woman presented to the emergency department with a 1 week history of vomiting, mild abdominal discomfort, and absolute constipation. The latter was preceded by gradual worsening of bile-stained non-projectile vomiting. She denied any fever or urinary symptoms. She was a type 2 diabetic and had a history of hypertension. She had no previous abdominal surgery. She was a non-smoker and denied recent alcohol consumption. On physical examination, she was apyrexial, pulse rate was 78 beats per minute, blood pressure was 110/60 mmHg, and respiratory rate was 25 breaths per minute. Her abdomen was soft and non-distended, but there was mild generalized tenderness elicited on palpation. There was no guarding or rebound tenderness. No obvious inguinal or femoral hernia on clinical examination. Digital rectal examination was unremarkable.\nLaboratory tests were as follows: White Blood Cells, 16.55 × 109/L; Hb, 14.1 g/dl; Platelet, 387 109/L × 109/L; Na, 118 mmol/L; K, 2.8 mmol/L; urea, 16.1 mmol/L; creatinine, 101 mmol/L; bilirubin (total), 18 μmol/L; alkaline phosphatase, 72 IU/L; and amylase, 69 IU/L. The arterial blood gas measurement suggested a hypochloremic metabolic alkalosis (pH 7.55, pCO2 6.17 kPa, bicarbonate 39.5 mmol/L, chloride 68 mmol/L, and lactate 1.7 mmol/L). Urine dipstick was negative for glucose, bilirubin, ketone, blood, protein, nitrates, and leukocytes.\nAn erect chest radiograph was normal with no evidence of subdiaphragmatic air []. Abdominal radiograph showed dilated small bowel loop in the central of abdomen []. For a detailed evaluation of the level of bowel obstruction, a contrast computed tomography (CT) of the abdomen and pelvis was requested. CT examination of the abdomen and pelvis showed findings consistent with proximal small bowel obstruction, pneumobilia located in the right hepatic lobe [], and a gallstone in the distal small bowel []. These features strongly suggested the diagnosis of gallstone ileus.\nAfter initial fluid resuscitation with 0.9% sodium chloride, correction of electrolyte imbalance, and nasogastric decompression, the patient underwent midline laparotomy. A proximal longitudinal enterotomy was performed. Numerous small bowel stones [] of variable size were “milked” distally. The largest stone measured 3.5 cm in diameter was retrieved from the small bowel lumen []. Each section of the bowels was inspected in a segmental fashion for sign of ischemia and other intra-luminal faceted gallstones. An abdominal washout was performed using warm saline in order to prevent gross peritoneal contamination. The abdominal incision was closed by a mass closure technique using an absorbable loop Maxon™ suture and staples to the skin. The fistula was left undisturbed and the patient made an uneventful recovery.