Biliary Trauma Clinical Presentation
- Author: Frederick Merrill Karrer, MD, FACS; Chief Editor: John Geibel, MD, DSc, MSc, MA more...
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- Suspect extrahepatic biliary tract trauma when the patient presents with a mechanism of injury consistent with the application of significant blunt force to the thoracoabdominal region. Mechanisms of injury can range from motor vehicle crashes to short falls.
- Penetrating trauma to the extrahepatic biliary tract may be obvious based on the external trajectory of the object, especially in stab wounds. In gunshot wounds to the abdomen, which may have a varied intra-abdominal trajectory, the path of injury may be less obvious.
- A patient's history of laparoscopic cholecystectomy, or any operative procedure in the right upper quadrant, is an important consideration in defining an extrahepatic biliary tract injury caused by a prior procedure.
Signs of trauma to the extrahepatic biliary tract caused by thoracoabdominal injury are as follows:
- Early signs of biliary leakage may be difficult to appreciate on physical examination.
- Hypovolemic shock can occur from intense chemical peritonitis when diagnosis is delayed. This can be followed by septic shock from bacterial overgrowth within a period of hours to days; however, with minimal biliary leakage, shock may not occur and abdominal signs may be absent.
- Jaundice is usually observed 3-5 days after injury, along with the passage of acholic stools and dark-colored urine.
- Increasing abdominal girth accompanied by signs of dehydration and low-grade sepsis may be observed during the first week after trauma.
- Direct observation with laparoscopy or laparotomy is used to aid in diagnosing penetrating extrahepatic biliary trauma.
- The hepatoduodenal ligament may show contusion, edema, fresh clot formation, or active bleeding.
Signs of trauma to the extrahepatic biliary tract caused by operative laparoscopy or laparotomy are as follows:
- Diagnosis of extrahepatic biliary tract trauma may be made during laparoscopy by direct observation of biliary drainage emanating from the porta hepatis or, if suspected, by contrast leak during an intraoperative cholangiogram. Notably, however, only a quarter of iatrogenic biliary injuries are discovered at the time of cholecystectomy.
- Extrahepatic biliary trauma may also be determined by patient complaints of abdominal pain, nausea, or increasing abdominal discomfort, occurring during the first week after laparoscopic cholecystectomy.
- Jaundice may also be present.
- Symptoms of cholangitis may be present in patients with delayed common bile duct stricture related to operative trauma.
See the list below:
- Blunt trauma mechanisms (eg, motor vehicle deceleration injuries, falls, assaults)
- Penetrating injuries caused by a simple direct force (eg, knife wound) or by a complex, indirect injury (eg, gunshot wound)
- Causes of laparoscopic injury to the extrahepatic biliary tract
- Direct trauma by grasping forceps
- Excessive use of electrocautery and dissection around the porta hepatis, causing tearing of the common bile duct wall or ischemia with resultant stricture formation
- Transection of the common bile duct or the right hepatic duct by not identifying the “critical view” during the cystic duct dissection
- Improper placement of clips, lacerating or occluding the extrahepatic biliary tract
- Endoscopic stenting of the biliary tree, increasing the incidence of iatrogenic injuries
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|1||Low common hepatic duct stricture, with a length of the common hepatic duct stump of >2 cm|
|2||Proximal common hepatic duct stricture, with a hepatic stump length of < 2 cm|
|3||Hilar stricture, no residual common hepatic duct, but the hepatic ductal confluence is preserved|
|4||Hilar stricture, with involvement of confluence and loss of communication between right and left hepatic duct|
|5||Involvement of aberrant right sectorial hepatic duct alone or with concomitant stricture of the common hepatic duct|
|A||Cystic duct leaks or leaks from small ducts in the liver bed|
|B||Occlusion of a part of the biliary tree, almost invariably the aberrant right hepatic ducts|
|C||Transection without ligation of the aberrant right hepatic duct|
|D||Lateral injuries to major bile ducts|
|E||Subdivided as per Bismuth’s classification into E1 to E5|
|Type of Injury||Criteria|
|Major bile duct injury|
(at least one of the following present)
|Laceration >25% of bile duct diameter|
Transection of common hepatic duct or common bile duct
Development of postoperative bile duct stricture
|Minor bile duct injury||Laceration of common bile duct < 25% of diameter|
Laceration of cystic-common bile duct junction ("buttonhole tear")
|Amsterdam Academic Medical Center’s classification||1996||A-D|
|Stewart-Way’s classification of laparoscopic bile duct injuries||2004||I-IV|
|Chinese University of Hong Kong (CUHK) classification||2007||1-5|