eMedicine Specialties > Trauma > Abdominal Trauma

Biliary Trauma: Treatment & Medication

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

Treatment

Surgical Care

  • Blunt extrahepatic biliary tract injury
    • Perform complete medial reflection of the duodenum to explore the retroperitoneal biliary system and to identify the injury.
    • Choledochoduodenostomy or choledochojejunostomy are currently the preferred methods of treatment. Simple peribiliary drainage is not recommended because of the high biliary stricture and mortality rates.
  • Penetrating extrahepatic biliary tract injury
    • Perform exploratory surgery on patients with significant penetrating abdominal trauma. If the patient is coagulopathic, hypothermic, and acidotic, perform damage control with 4-quadrant packing and intensive care unit resuscitation.
    • Acutely control hepatoduodenal hemorrhage by compression of the hepatoduodenal ligament (Pringle maneuver).
    • After proximal and distal control of the hepatoduodenal ligament is obtained, dissect apart the bile duct, the portal vein, and the hepatic artery to identify injury to each structure.
    • If the bile duct is completely transected, perform a biliary-enteric anastomosis (eg, Roux-en-Y choledochojejunostomy). If the duct is partially transected, then primary repair may be possible; a T-tube may be required in such instances.
    • If the patient cannot tolerate a lengthy operative procedure, a T-tube bridge between the ends of the defect may be possible; however, to avoid the sequelae of recurrent biliary strictures, perform definite repair at a later date. Anastomosis between the gallbladder and a loop of the small intestine with ligation of the proximal and distal ends of the injured common bile duct may be more expeditious.
  • Laparoscopic extrahepatic biliary tract injury (2 categories)
    • Minor ductal injuries are those that have intact ductal anatomy without associated strictures (eg, tangential holes in the sidewall of the bile duct from ischemic injury, thermal injury, excessive stripping of the common duct wall). Sphincterotomy and stenting are helpful in controlling the biliary fistula; however, operative reconstruction is necessary if a stricture later develops.
    • Major ductal injuries to the common bile duct occur when large segments of the duct are excised, severely destroyed, or occluded by clips. Practically all of these injuries require formal operative repair.
  • Gallbladder injury
    • Cholecystectomy is the best treatment of most injuries of the gallbladder regardless of the mechanism of injury.
    • When injury of other organs or hemodynamic instability precludes cholecystectomy, perform cholecystostomy. This usually requires the placement of drains around the subhepatic space. The cholecystostomy tube can be removed after one month, providing a cholangiogram shows normal biliary flow.
    • Primary suture repair of the gallbladder is not recommended because of the high likelihood of bile leakage.

Consultations

  • Ensure that a surgeon or a trauma specialist has primary responsibility for the care of all patients with biliary trauma caused by traumatic mechanisms.
  • Ensure that a surgeon qualified in general surgical, endoscopic, and laparoscopic techniques is involved in the care of patients with operative and iatrogenic injury to the extrahepatic biliary tract.

Diet

  • Patients with a complex postoperative course may be fed by a transpyloric feeding tube that is placed intraoperatively.
  • Patients may resume a regular diet after postoperative ileus has resolved.

Activity

No activity restrictions are required for isolated extrahepatic bile duct system injuries.

More on Biliary Trauma

Overview: Biliary Trauma
Differential Diagnoses & Workup: Biliary Trauma
Treatment & Medication: Biliary Trauma
Follow-up: Biliary Trauma
References
[ CLOSE WINDOW ]

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].

[ CLOSE WINDOW ]

Further Reading

[ CLOSE WINDOW ]

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

[ CLOSE WINDOW ]

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

 
 
HONcode

We subscribe to the
HONcode principles of the
Health On the Net Foundation

All material on this website is protected by copyright, Copyright© 1994- by Medscape.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.