Pneumobilia Is a Risk Factor for Multiple Episodes of Recurrent Choledocholithiasis After ERCP With Biliary Sphincterotomy

Pancreatobiliary

Rajesh N. Keswani, MD, MS reviewing Dong H, et al. Gastrointest Endosc 2023 Nov 19.

Pneumobilia (air within the bile duct) frequently occurs after ERCP with biliary sphincterotomy. Although this is generally considered a benign finding after sphincterotomy, there has been some prior research that pneumobilia is a risk factor for recurrent common bile duct stones (CBDS). 

In this single-center retrospective study, the authors identified 1380 patients who previously underwent ERCP with biliary sphincterotomy. Of these patients, 184 had preceding imaging to confirm the presence or absence of pneumobilia, which was defined as the presence of air in the bile ducts as seen on cross-sectional imaging more than 3 months after the initial ERCP. The authors performed propensity matching to determine the impact of pneumobilia on recurrent CBDS (developed ≥3 months after index ERCP). They found that pneumobilia did not significantly impact the likelihood of developing recurrent CBDS. However, the incidence of multiple recurrences of CBDS was significantly higher in the pneumobilia group than in the nonpneumobilia group (32.5% vs 12.5%; P=.032) after propensity matching.

The authors also found that the incidence of acute cholangitis (unrelated to stone recurrence) was significantly higher in the pneumobilia group than in the nonpneumobilia group and that periampullary diverticula, a dilated common duct, and a moderate to large sphincterotomy were independent risk factors for the development of pneumobilia.


Comment:

In summary, this small study identified pneumobilia as an independent risk factor for the development of multiple episodes of recurrent CBDS and cholangitis. Pneumobilia on cross-sectional imaging likely represents a more patulous biliary sphincter—and resultant increase in bacterial reflux and secondary stone formation—after ERCP with biliary sphincterotomy. Although knowing that pneumobilia is a risk factor for CBDS is helpful, whether medications can prevent recurrent episodes is unclear.
Note to readers: At the time we reviewed this paper, its publisher noted that it was not in final form and that subsequent changes might be made.

Rajesh N. Keswani, MD, MS

Bio and Disclosures

Citation(s):

Dong H, Zhang W, Lyu X, et al. Long-term prognosis and risk factors associated with post-ERCP pneumobilia in patients with common bile duct stones. Gastrointest Endosc 2023 Nov 19. (Epub ahead of print) (https://doi.org/10.1016/j.gie.2023.11.016)