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Biliary Trauma Clinical Presentation

  • Author: Frederick Merrill Karrer, MD, FACS; Chief Editor: John Geibel, MD, DSc, MSc, MA  more...
 
Updated: Oct 20, 2014
 

History

See the list below:

  • 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.
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Physical

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.
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Causes

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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Contributor Information and Disclosures
Author

Frederick Merrill Karrer, MD, FACS Professor of Surgery and Pediatrics, Head, Division of Pediatric Surgery, University of Colorado School of Medicine; The Dr David R and Kiku Akers Chair in Pediatric Surgery, Surgical Director, Pediatric Transplantation, The Children’s Hospital

Frederick Merrill Karrer, MD, FACS is a member of the following medical societies: American Academy of Pediatrics, American Association for the Study of Liver Diseases, Children's Oncology Group, International Liver Transplantation Society, Transplantation Society, International Society of Paediatric Surgical Oncology, Pacific Association of Pediatric Surgery, International Pediatric Transplant Association, Colorado Medical Society, Society of Critical Care Medicine, American College of Surgeons, American Medical Association, American Pediatric Surgical Association, American Society of Transplant Surgeons, Western Surgical Association

Disclosure: Nothing to disclose.

Coauthor(s)

Matthew P Landman, MD, MPH Fellow in Pediatric Surgery, Children’s Hospital Colorado

Matthew P Landman, MD, MPH is a member of the following medical societies: American College of Surgeons, American Pediatric Surgical Association, Society of American Gastrointestinal and Endoscopic Surgeons

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Robert L Sheridan, MD Assistant Chief of Staff, Chief of Burn Surgery, Shriners Burns Hospital; Associate Professor of Surgery, Department of Surgery, Division of Trauma and Burns, Massachusetts General Hospital and Harvard Medical School

Robert L Sheridan, MD is a member of the following medical societies: American Academy of Pediatrics, American Association for the Surgery of Trauma, American Burn Association, American College of Surgeons

Disclosure: Received research grant from: Shriners Hospitals for Children; Physical Sciences Inc<br/>Received income in an amount equal to or greater than $250 from: SimQuest Inc -- consultant on burn mapping softwear ($1,500).

Chief Editor

John Geibel, MD, DSc, MSc, MA Vice Chair and Professor, Department of Surgery, Section of Gastrointestinal Medicine, and Department of Cellular and Molecular Physiology, Yale University School of Medicine; Director, Surgical Research, Department of Surgery, Yale-New Haven Hospital; American Gastroenterological Association Fellow

John Geibel, MD, DSc, MSc, MA is a member of the following medical societies: American Gastroenterological Association, American Physiological Society, American Society of Nephrology, Association for Academic Surgery, International Society of Nephrology, New York Academy of Sciences, Society for Surgery of the Alimentary Tract

Disclosure: Received royalty from AMGEN for consulting; Received ownership interest from Ardelyx for consulting.

Additional Contributors

Ernest Dunn, MD Program Director, Surgery Residency, Department of Surgery, Methodist Health System, Dallas

Ernest Dunn, MD is a member of the following medical societies: American College of Surgeons, American Medical Association, Association for Academic Surgery, Society of Critical Care Medicine, Texas Medical Association

Disclosure: Nothing to disclose.

Acknowledgements

Jose Fernando Aycinena Goicolea, MD Colorectal Surgeon, Somerset Surgical Services, Somerset Hospital

Jose Fernando Aycinena Goicolea, MD is a member of the following medical societies: American College of Surgeons and Pennsylvania Medical Society

Disclosure: Nothing to disclose. Anastasios K Konstantakos, MD Clinical Associate Surgeon, Department of Cardiovascular Surgery, Billings Clinic

Disclosure: Nothing to disclose.

Jeffrey L Ponsky, MD Chairman, Case Western Reserve University; Professor, Department of Surgery, University Hospitals of Cleveland

Jeffrey L Ponsky, MD is a member of the following medical societies: American Association for the Study of Liver Diseases, American College of Gastroenterology, American College of Surgeons, American Gastroenterological Association, American Medical Association, American Surgical Association, and Association for Academic Surgery

Disclosure: Nothing to disclose.

References
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Table 1. Bismuth's Classification (1982)[4]
TypeCriteria
1Low common hepatic duct stricture, with a length of the common hepatic duct stump of >2 cm
2Proximal common hepatic duct stricture, with a hepatic stump length of < 2 cm
3Hilar stricture, no residual common hepatic duct, but the hepatic ductal confluence is preserved
4Hilar stricture, with involvement of confluence and loss of communication between right and left hepatic duct
5Involvement of aberrant right sectorial hepatic duct alone or with concomitant stricture of the common hepatic duct
Table 2. Strasberg's Classification (1995)[4]
TypeCriteria
ACystic duct leaks or leaks from small ducts in the liver bed
BOcclusion of a part of the biliary tree, almost invariably the aberrant right hepatic ducts
CTransection without ligation of the aberrant right hepatic duct
DLateral injuries to major bile ducts
ESubdivided as per Bismuth’s classification into E1 to E5
Table 3. Definition of Major and Minor Bile Duct Injures by McMahon et al (1995)[4]
Type of InjuryCriteria
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 injuryLaceration of common bile duct < 25% of diameter



Laceration of cystic-common bile duct junction ("buttonhole tear")



Table 4. Summary of Additional Classification Systems[4]
Classification SystemYearTypes
Amsterdam Academic Medical Center’s classification1996A-D
Neuhaus’ classification2000A-E
Csendes’ classification2001I-IV
Stewart-Way’s classification of laparoscopic bile duct injuries2004I-IV
Chinese University of Hong Kong (CUHK) classification20071-5
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