PNEUMOBILIA VERSUS PORTAL VENOUS GAS IN BLUNT ABDOMINAL TRAUMA

Editor,

Hepatic portal venous gas (HPVG) and pneumobilia secondary to blunt abdominal trauma are rare CT findings. Appearances are similar and can lead to diagnostic confusion. HPVG, was first described by Wolfe and Evans in 1955¹ in relation to non-reversible intra-abdominal pathology in post mortem infants. Other causes have subsequently been described, but it is a rare finding in blunt abdominal trauma². Pneumobilia has been reported in the context of emphysematous cholecystitis, passage of a biliary stone and endoscopic retrograde cholangiopancreatography (ERCP) but rarely in trauma.³

The following case supports the postulate that neither pathology is an absolute indication for exploratory laparotomy in an otherwise stable patient.

CASE REPORT

A 61-year-old white male was transferred 25 miles from the scene of a high-speed road traffic accident to the Royal Victoria Hospital. He was the driver of a car involved in a head on collision. He was restrained by his seatbeat and entrapped for 45 minutes due to driver compartment intrusion. Type II diabetes was his only significant past medical history.

He arrived in the resuscitation department 88 minutes after impact. He had been immobilised at the scene. Primary survey revealed haemodynamic stability and a GCS of 15/15. He was vomiting copious amounts of clear fluid with associated severe generalised abdominal, right-sided chest and lower back pain. He had both a seatbelt sign and extensive bruising across his right lateral chest and back. Bloods including amylase were unremarkable. A full-body Trauma CT scan was conducted. The initial report identified significant global injuries including; a mid-shaft fracture of the right clavicle, multiple right-sided rib fractures, an unstable two column fracture of L5 vertebral body, traumatic liver laceration with associated pneumobilia segment 4A (figure 1), right posterior transverse abdominus avulsion, extensive thickening of the small bowel, flattening of the IVC and hyperenhancing adrenals suggesting hypovolaemia and shock. No mesenteric haematoma, free fluid or pneumoperitoneum was present.

Fig 1.

Gas in liver initially described as pneumobilia reported on review of images as portal venous gas, given peripheral distribution away from the main biliary tree.

On surgical reassessment the patient remained generally tender despite analgesia however haemodynamically was stable with no peritonitis. The decision was made not to proceed to immediate laparotomy. The patient was transferred to the High Dependence Unit for monitoring. Intubation was not required.

The following day radiology review suggested the gas within the liver was in the portal venous system (HPVG), likely related to acute gastric dilatation as gas was also seen within the stomach wall dependently in the left upper quadrant (gastric pneumatosis) (figure 2), with small foci of gas in the adjacent gastric veins. As he remained stable we continued conservative management and the patient was successfully discharged home 21 days post admission.

Fig 2.

Incidental finding of gas within stomach wall

Our case adds to the growing body of evidence that post-traumatic HPVG and pneumobilia are surrogate markers of significant trauma but neither sign in isolation should prompt immediate exploratory laparotomy in an otherwise stable patient.

Written informed consent was obtained from the patient for publication of this case report and any accompanying images.