Abstract
Biliary pneumatosis has recently been reported in intrahepatic amd extrahepatic bile ducts complicating bacterial cholangitis, as characterized by cholangioscopy. This clinical report adds another case of small‐scale pneumatosis cysts in the common bile duct to the literature. Similary to previously reported cases, the recent patient likewise had a history of acute cholangitis. It might be tempting to speculate that this finding might prove more common than expected in the dawning era of routine use of cholangioscopic characterization of biliary tract diseases.
Keywords: cholangioscopy, cholangitis, endoscopic retrograde cholangiopancreatography
Despite >50 years of ERCP practice, biliary tract pneumatosis cysts have only recently been described in a setting of cholangitis. More routine use of cholangioscopy may help assess its true incidence and clinical relevance in the future.
First‐time cholangioscopic visualization of intrahepatic pneumatosis has only recently been provided. 1 Direct cholangioscopy after complex biliary access exhibited prominent submuocsal blebs, and the gas‐filled lesional nature was confirmed by needle puncture. It remains fascinating that in the dawning era of direct endoscopic visulization, it took >50 years of ERCP to provide such seminal description. By contrast, cholangitis‐related changes in the cholangiographic shilouette, for example, outer margin corrugation, have been appreciated for a long time. While similar findings were reported in ultrasound literature including marked cholangitis‐induced wall thickening, the mechanisms underlying biliary pneumatosis remain speculative, albeit cholangitis‐related mucosal barrier dysfunction and/or bacterial wall invasion might be discussed. Notwithstanding, low‐level biliary pneumatosis following cholangitis has been observed in my cholangioscopy practice twice, since its first description, suggesting that biliary pneumatosis may not be that uncommon. 2 To expand this experience, Figure 1 illustrates small‐scale biliary pneumatosis on ultra‐slim cholangioscopy three weeks after clinical resolution of cholangitis. Overall, it remains tempting to assume that biliary pneumatosis might represent a signature marker for preceding cholangitis and the true incidence of this finding might become better appraised along the expected more routine use of cholangioscopy in bile duct diseases.
FIGURE 1.
(A, B) Direct cholangioscopy using an ultra‐slim upper endoscope after freehand access illustrating two small‐scale submucosal, glassy lesions with smooth mucosal covering in the common bile duct, highly suggestive of minor biliary pneumatosis after clinical cholangitis resolution
CONFLICT OF INTEREST
Nothing to declare.
AUTHOR CONTRIBUTIONS
VZ, clinical and endoscopic care, drafting and finalization of the manuscript.
CONSENT
Written informed consent was obtained from the patient to publish this report in accordance with the journal's patient consent policy.
Zimmer V. Cholangitis‐related biliary pneumatosis cysts in the dawning era of routine direct endoscopic visualization of biliary diseases. Clin Case Rep. 2022;10:e05790. doi: 10.1002/ccr3.5790
DATA AVAILABILITY STATEMENT
Data available on request due to privacy/ethical restrictions
REFERENCES
- 1. Mangas‐Sanjuan C, Martinez‐Moreno B, Martinez J, et al. Biliary pneumatosis: a new finding in a patient with cholangitis. Endoscopy. 2020;53(6):E211‐E212. [DOI] [PubMed] [Google Scholar]
- 2. Zimmer V, Heinrich C. Direct endoscopic visualization of putative biliary tract pneumatosis cysts by ultraslim cholangioscopy. Gastrointest Endosc. 2021;93(6):1426‐1427. [DOI] [PubMed] [Google Scholar]
Associated Data
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Data Availability Statement
Data available on request due to privacy/ethical restrictions