Portal de Periódicos da CAPES

Air in the Hepatic Ducts: An X-ray Sign of Biliary Fistula

1936; Radiological Society of North America; Volume: 27; Issue: 4 Linguagem: Inglês

10.1148/27.4.474

1527-1315

Robert A. Powers,

Esophageal and GI Pathology

SPONTANEOUS biliary fistulæ are probably not as rare as is generally supposed. Before the advent of the roentgen ray, clinical diagnosis of this condition was rarely made. Moller (1), quoted by G. A. Moore, states that out of 22 cases of gallstone ileus which he operated upon, the correct diagnosis was made in three cases. Courvoisier (2) states that about 4 per cent of his cases of intestinal obstruction from all causes were due to gallstones. Powers (3) found four cases, or 2.2 per cent, in 179 operations for intestinal obstruction. Kehr (4) found 100 fistulæ, or about 5 per cent, in 2,000 gall-bladder operations. Since roentgen-ray examinations have come into general use, diagnoses of biliary fistulæ have been more frequent. In 1933, Firor (5) collected 40 odd cases from the roentgen literature. As the writer has seen four cases in one small hospital, there appears to be no question but that many times this number have been unreported. Firor credits Busic with having made the first roentgen diagnosis in 1919. In 1920, Carman (6) reported a case in which a pyloric carcinoma had ulcerated into the gall bladder: barium found its way into the hepatic ducts. In 1925, Havlicek (7) reported a case and stated that the condition had not been previously described. In 1933, Lucas Henry (8) reported a beautifully illustrated case in which the bile ducts were outlined first by air and then by barium. Biliary fistulæ are usually due to the erosion or ulceration of large gallstones, but may result from benign or malignant ulcerations and may originate in either the gastro-intestinal or biliary tracts; duodeno-biliary fistulæ are by far the most common. In the 40-odd cases collected by Firor, 36 were duodeno-biliary fistulæ; four biliary colic fistulæ; two hepatobronchial fistulæ, and one gastro-biliary fistula. Von Schlapfer (9) states that in one case a stone was expelled in the vomitus and a gastro-biliary fistula was subsequently found. Fistulæ have also been reported between the gall bladder and kidney and the gall bladder and the urinary bladder (10). One case is said to have voided 200 stones in the urine. Roentgen findings in biliary fistula may be air or barium in the hepatic ducts or a large solitary calculus with a facet. Air in the bile ducts must be a common finding as it was present in three of the four cases observed by the writer. Air shadows are usually tubular or branched, and follow the general direction of the common duct. Air may surround a calculus in the gall bladder and cause a crescentic shadow. Upon two occasions the writer has observed tubular transparent shadows arising near the spine and extending downward from left to right. I can find no adequate explanation of these pseudo-air shadows. They may be due to fat in the ligamentum teres hepatis. One of these cases was operated upon for a perforating duodenal ulcer and no fistula was present. Air or barium rarely enters the hepatic ducts except through a biliary fistula.