eMedicine Specialties > Trauma > Abdominal Trauma

Biliary Trauma: Differential Diagnoses & Workup

Author: Jose Fernando Aycinena, MD, Staff Physician, Department of General Surgery, University of Tennessee Graduate School of Medicine
Coauthor(s): Anastasios K Konstantakos, MD, Clinical Associate Surgeon, Brigham and Women's Hospital, Harvard University; Jeffrey L Ponsky, MD, Chairman, Case Western Reserve University; Professor, Department of Surgery, University Hospitals of Cleveland
Contributor Information and Disclosures

Updated: Aug 14, 2008

Differential Diagnoses

Abdominal Trauma, Blunt
Abdominal Trauma, Penetrating
Abdominal Vascular Injuries
Pancreatic Trauma

Other Problems to Be Considered

Associated injury to the portal vein, the hepatic artery, the pancreas, and the liver

Workup

Imaging Studies

  • Abdominal CT scanning can evaluate the right upper quadrant in blunt abdominal trauma cases.
  • Transabdominal sonography may be useful to observe a bile leak or a dilated common bile duct.
  • Endoscopic retrograde cholangiopancreatography (ERCP) may be useful for the diagnosis of suspected, but not obvious, extrahepatic biliary tract trauma from laparoscopic operation.
  • Percutaneous transhepatic cholangiography may also be indicated for delineation of the anatomy in more complicated cases.
  • Intraoperative ultrasonography can provide important information by aiding in localization of occult injuries. However, it is highly operator dependent.
  • Magnetic resonance cholangiopancreatography (MRCP) has been shown to be useful in detecting pancreaticobiliary injuries after blunt trauma.

Procedures

  • In patients with extrahepatic biliary tract trauma caused by nonoperative mechanisms (eg, thoracoabdominal trauma), diagnostic peritoneal lavage may be useful for detecting bile or nonclotting blood in the peritoneal fluid.
  • In patients with possible laparoscopic trauma to the extrahepatic biliary tract, concomitant sphincterotomy of the sphincter of Oddi and possible stenting may be appropriate.

Staging

Several injury classification systems have been described for biliary tract trauma. Most of them are in the context of iatrogenic injuries during cholecystectomy and provide a recommended surgical approach for repair.

None of the classification systems is universally accepted, but the classification systems of Bismuth and Strasberg are presently the most widely used.

Table 1. Bismuth's Classification (1982)1

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Table
Type
Criteria
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
Type
Criteria
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


Table 2. Strasberg's Classification (1995)1

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Table
Type
Criteria
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
Criteria
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

McMahon et al suggested that the type of injury can be subdivided into bile duct laceration, bile duct transection or excision, and bile duct stricture. The level of stricture may be further graded by Bismuth's classification and also makes a distinction on the size of the duct (major vs minor).

Table 3. Definition of Major and Minor Bile Duct Injures by McMahon et al (1995)1

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Table
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")
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")

More comprehensive classification systems have been described; some of them include various types of laparoscopic extrahepatic bile duct injuries and cover the whole spectrum of possible lesions.

Table 4. Summary of Classification Systems1

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Table
Classification System
Year
Types
AmsterdamAcademicMedicalCenter's classification

1996
A-D
Neuhaus' classification
2000
A-E
Csendes' classification
2001
I-IV
Stewart-Way's classification of laparoscopic bile duct injuries
2004
I-IV
ChineseUniversity of Hong Kong (CUHK) classification
2007
1-5
Classification System
Year
Types
AmsterdamAcademicMedicalCenter's classification

1996
A-D
Neuhaus' classification
2000
A-E
Csendes' classification
2001
I-IV
Stewart-Way's classification of laparoscopic bile duct injuries
2004
I-IV
ChineseUniversity of Hong Kong (CUHK) classification
2007
1-5

More on Biliary Trauma

Overview: Biliary Trauma
Differential Diagnoses & Workup: Biliary Trauma
Treatment & Medication: Biliary Trauma
Follow-up: Biliary Trauma
References
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References

  1. Lau WY, Lai EC. Classification of iatrogenic bile duct injury. Hepatobiliary Pancreat Dis Int. Oct 2007;6(5):459-63. [Medline].

  2. Busuttil RW, Kitahama A, Cerise E, et al. Management of blunt and penetrating injuries to the porta hepatis. Ann Surg. May 1980;191(5):641-8. [Medline].

  3. Carmichael DH. Avulsion of the common bile duct by blunt trauma. South Med J. Feb 1980;73(2):166-8. [Medline].

  4. Chi KD, Waxman I. Subcapsular hepatic hematoma after guide wire injury during endoscopic retrograde cholangiopancreatography: management and review. Endoscopy. Nov 2004;36(11):1019-21. [Medline].

  5. de Reuver PR, Rauws EA, Bruno MJ, et al. Survival in bile duct injury patients after laparoscopic cholecystectomy: a multidisciplinary approach of gastroenterologists, radiologists, and surgeons. Surgery. Jul 2007;142(1):1-9. [Medline].

  6. Erkan M, Bilge O, Ozden I, et al. Definitive treatment of traumatic biliary injuries. Ulus Travma Derg. Oct 2004;10(4):221-5. [Medline].

  7. Gupta A, Stuhlfaut JW, Fleming KW, et al. Blunt trauma of the pancreas and biliary tract: a multimodality imaging approach to diagnosis. Radiographics. Sep-Oct 2004;24(5):1381-95. [Medline].

  8. Machi J, Oishi AJ, Furumoto NL, Oishi RH. Intraoperative ultrasound. Surg Clin North Am. Aug 2004;84(4):1085-111, vi-i. [Medline].

  9. Ponsky JL. Endoscopic approaches to common bile duct injuries. Surg Clin North Am. Jun 1996;76(3):505-13. [Medline].

  10. Ragozzino A, Manfredi R, Scaglione M, et al. The use of MRCP in the detection of pancreatic injuries after blunt trauma. Emerg Radiol. Apr 2003;10(1):14-8. [Medline].

  11. Sawaya DE Jr, Johnson LW, Sittig K, et al. Iatrogenic and noniatrogenic extrahepatic biliary tract injuries: a multi-institutional review. Am Surg. May 2001;67(5):473-7. [Medline].

  12. Shires GT, Thal ER, Jones RC. Trauma. In: Schwartz SI, ed. Principles of Surgery. 6th ed. New York, NY: McGraw-Hill; 1994:175-224.

  13. Sicklick JK, Camp MS, Lillemoe KD, et al. Surgical management of bile duct injuries sustained during laparoscopic cholecystectomy: perioperative results in 200 patients. Ann Surg. May 2005;241(5):786-92; discussion 793-5. [Medline].

  14. Sriram PV, Ramakrishnan A, Rao GV, et al. Spontaneous fracture of a biliary self-expanding metal stent. Endoscopy. Nov 2004;36(11):1035-6. [Medline].

  15. Walsh RM, Henderson JM, Vogt DP, et al. Long-term outcome of biliary reconstruction for bile duct injuries from laparoscopic cholecystectomies. Surgery. Oct 2007;142(4):450-6; discussion 456-7. [Medline].

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Further Reading

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Keywords

biliary trauma, biliary injury, biliary tract trauma, extrahepatic biliary tract trauma, gallbladder trauma, bile duct injury, bile duct stricture, bile leak, laparoscopic cholecystectomy, biliary stricture, EBT trauma, GB trauma, EBT, GB

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Contributor Information and Disclosures

Author

Jose Fernando Aycinena, MD, Staff Physician, Department of General Surgery, University of Tennessee Graduate School of Medicine
Jose Fernando Aycinena, MD is a member of the following medical societies: American College of Surgeons and Tennessee Medical Association
Disclosure: Nothing to disclose.

Coauthor(s)

Anastasios K Konstantakos, MD, Clinical Associate Surgeon, Brigham and Women's Hospital, Harvard University
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.

Medical Editor

Ernest Dunn, MD, Program Director of General Surgery, Director of Trauma and Critical Care, Clinical Associate Professor, Department of Surgery, Methodist Hospitals of Dallas, University of Texas Southwestern
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, and Texas Medical Association
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

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, and American College of Surgeons
Disclosure: Nothing to disclose.

CME Editor

Paolo Zamboni, MD, Professor of Surgery, Chief of Day Surgery Unit, Chair of Vascular Diseases Center, University of Ferrara, Italy
Paolo Zamboni, MD is a member of the following medical societies: American Venous Forum and New York Academy of Sciences
Disclosure: Nothing to disclose.

Chief Editor

John Geibel, MD, DSc, MA, Vice Chairman, Professor, Department of Surgery, Section of Gastrointestinal Medicine and Department of Cellular and Molecular Physiology, Yale University School of Medicine; Director of Surgical Research, Department of Surgery, Yale-New Haven Hospital
John Geibel, MD, DSc, 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, and Society for Surgery of the Alimentary Tract
Disclosure: AMGEN Royalty Other; AstraZeneca Grant/research funds Other

 
 
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