Biliary Trauma 

Updated: Mar 27, 2020
Author: Frederick Merrill Karrer, MD, FACS; Chief Editor: John Geibel, MD, MSc, DSc, AGAF 

Overview

Practice Essentials

Biliary trauma is rare and includes injury to the bile ducts or gallbladder. Clinicians should have a high index of suspicion in patients who sustain significant right upper quadrant blunt or penetrating injury.[1]

Diagnosis is often delayed, which may increase associated morbidity and mortality.

Endoscopic retrograde cholangiopancreatography (ERCP) has become a minimally invasive strategy to manage partial duct transections and should be considered in hemodynamically stable patients.

Signs and symptoms

Most of the morbidity associated with biliary tract injuries is related to bile leaking into the peritoneal cavity; however, with minimal bile leakage, peritonitis may not occur initially and abdominal signs may be absent. Thus, initial physical findings are often nonspecific.

Late physical findings may include the following:

  • Right upper quadrant pain
  • Peritonitis
  • Jaundice

See Presentation for more detail.

Diagnosis

Laboratory studies

No specific laboratory values exist to diagnose traumatic bile duct injuries. Concurrent liver injuries will likely result in elevated aspartate aminotransferase (AST) and alanine aminotransferase (ALT) levels, which should raise suspicion for a biliary injury.

Imaging studies

The following imaging studies have been used in the evaluation of biliary trauma:

  • Focused assessment with sonography for trauma (FAST): Used to detect fluid in the peritoneal cavity.
  • Abdominal computed tomography (CT): Can be helpful in determining the etiology of fluid in the right upper quadrant; can also be used to assess for concomitant liver injury in patients with  blunt abdominal trauma.
  • 99mTc-Mebrofenin hybrid single photon emission tomography-computed tomography (SPECT-CT): Used to detect and localize posttraumatic bile leaks. [2]
  • Magnetic resonance cholangiopancreatography (MRCP): Useful for detecting pancreaticobiliary injuries after blunt trauma.
  • HIDA (Tc 99m-hepatobiliary iminodiacetic acid) scintigraphy: May demonstrate leakage from the biliary tree.
  • Endoscopic retrograde cholangiopancreatography (ERCP): Extremely useful for the diagnosis of biliary trauma in stable patients and allows for therapeutic intervention in selected patients.

See Workup for more detail.

Management

The choice of treatment depends on the following factors:

  • Patient stability
  • Associated injuries
  • Imaging findings

If the clinician has a high index of suspicion for concurrent injuries other than a solid organ injury, a diagnostic laparoscopy or exploratory laparotomy may be indicated. In the rare event that an isolated extrahepatic bile duct or gallbladder injury is identified on imaging, endoscopic techniques may be favored.

See Treatment for more detail.

Background

Injury to the biliary tract or gallbladder is an uncommon event, with an incidence of less than 1% among individuals suffering from abdominal trauma. Predisposing mechanisms include blunt right upper quadrant force, deceleration injury, and penetrating injury.

This review considers intrahepatic and extrahepatic bile duct and gallbladder injuries resulting from blunt and penetrating trauma. The diagnostic and management strategies as well as associated morbidity and mortality are also reviewed.

Pathophysiology

Intrahepatic bile duct injuries often occur in conjunction with liver injuries. The American Association for the Surgery of Trauma (AAST) categorizes liver lacerations based on parenchymal disruption, with a subcapsular hematoma classified as a grade I injury and complete hepatic evulsion as a grade VI injury.[3]  A direct correlation between the severity of liver injury and the likelihood of developing an intrahepatic biliary leak has been reported.[4]

A tremendous amount of force must be generated to disrupt the extrahepatic biliary system. Among extrahepatic biliary injuries, complete transection of the suprapancreatic common bile duct occurs most commonly. The next most common injury is transection of the intrapancreatic common bile duct, followed by laceration of the left hepatic duct.[1]

Gallbladder injuries occur less frequently than bile duct injuries. While right upper quadrant blunt force has been proposed as a risk factor for gallbladder injury, 89% of injuries to the gallbladder occur following penetrating trauma.[5]

Outcomes following biliary trauma are dependent upon multiple factors: the extent of injury, the time between injury and diagnosis, and the location (retroperitoneal vs intraperitoneal). The average delay until diagnosis has been reported to be 11 days but ranges from a few hours to several months after injury.[1]  Depending on the location, these injuries may result in contained leaks or bile peritonitis.    

Epidemiology

Although the frequency of biliary injury following blunt trauma has not been well characterized, small series suggest an incidence of 1-6% among all patients with traumatic liver injuries.[6, 7, 8]  A majority of the data comes from pediatric centers and suggests that children with liver lacerations extending to the porta hepatis are more likely to suffer from an intrahepatic bile duct injury than those with less severe liver injuries.[9]

Extrahepatic biliary trauma is rare, accounting for less than 1% of all blunt abdominal injuries in most series. In a systematic review of 51 manuscripts, Pereira et al identified 66 patients with extrahepatic bile duct injuries following blunt trauma, highlighting the infrequency of such injuries.[1]

Similarly, gallbladder injury is also an uncommon occurrence following trauma. Ball et al described a decade's experience at a level 1 trauma center. Among the more than 40,000 trauma patients evaluated over the study period, 45 (0.1%) were found to have a gallbladder injury and associated injuries were identified in 98% of cases. A majority (89%) of gallbladder injuries resulted from penetrating trauma.[5]

The rarity of traumatic biliary injuries limits the ability to formalize a staging system, although staging systems do exist to describe iatrogenic bile duct injuries.

Sex- and age-related demographics

Approximately 75% of cases have been reported in males.[1]  Biliary trauma can occur at any age, but like all blunt and penetrating trauma, it is more common in adolescents and young adults.[10]

Prognosis

Survival related specifically to injuries to the biliary system is excellent. Long-term morbidity is often associated with concurrent injuries, delay in diagnosis, or complications associated with biliary system repair, such as strictures.

Morbidity/mortality

Mortality is most often related to associated injuries. Morbidity, on the other hand, may be dependent upon the time to diagnosis and treatment as well as the severity of the injury and associated insults. In a review of patients with bile duct trauma who were initially managed non-operatively, the mean time to diagnosis was 11 days.[1]

Patients with injuries that are promptly discovered and managed within hours have a mortality rate of less than 10%, while patients with extensive injuries and delayed treatment may have a mortality rate approximating 40%.

Most of the morbidity associated with injury to the biliary tract is related to bile leaking into the peritoneal cavity. While the initial insult is a chemical peritonitis, bacterial contamination has been reported and may precipitate distributive shock following biliary trauma.[11, 12]

Complications

Complications associated with a bile duct or gallbladder injury are frequently a consequence of delay in diagnosis. This delay is particularly common among patients who sustain blunt thoracoabdominal trauma and are managed non-operatively. As a result of a missed injury, bile may leak into the abdominal cavity, resulting in chemical peritonitis. This in turn may lead to increased reabsorption of bile, causing hyperbilirubinemia and jaundice. 

Late complications that may arise from the trauma itself or from its treatment include the following:

  • Bilomas
  • Strictures
  • Hemobilia

Bilomas result from a bile leak forming a localized collection. These may be treated by ERCP and stenting to preferentially promote bile drainage into the duodenum with or without percutaneous drainage by interventional radiology.

Strictures may cause infectious complications (eg, cholangitis), stone formation, or chronic liver problems (eg, cirrhosis). If detected, strictures can be treated by ERCP, dilation, and stenting. Chronic, persistent strictures may require bilio-enteric bypass with either hepaticojejunostomy or hepaticoduodenostomy.

Hemobilia is a rare but potentially devastating complication following biliary trauma.  Approximately half of hemobilia cases occur after liver trauma, usually penetrating.[13]  Presenting symptoms include abdominal pain, hematemesis, melena, and jaundice.  Diagnosis requires upper endoscopy and often computed tomography angiography (CTA). Although angiography with embolization is successful in the majority of cases, when it fails, urgent surgical division of the fistula is warranted. For fistulas associated with the intrahepatic biliary system, a partial hepatectomy may be required.  

 

Presentation

History

Clinicians should suspect biliary trauma when a patient presents following a significant blunt force injury to the right thoracoabdominal region. Mechanisms of injury include motor vehicle deceleration injuries, falls, and assaults. 

Penetrating trauma to the biliary tract may be suspected based on the external trajectory of the object, specifically 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.  

 

Physical Examination

Among patients who present in shock at the time of injury, the source is likely hemorrhagic from associated injuries and not due to a biliary injury. As noted above, chemical peritonitis may develop; however, with minimal bile leakage, peritonitis may not occur initially, and abdominal signs may be absent. Thus, physical examination findings are often nonspecific. Late physical findings, on the other hand, may include right upper quadrant pain, peritonitis, and jaundice. Signs specific for trauma to the biliary system include the following:

  • Jaundice may be observed as early as 3-5 days after injury; however, it may take several weeks to become obvious.
  • Increasing abdominal girth from biliary ascites, accompanied by signs of dehydration, may develop during the first week after trauma.
  • Following a laparotomy, missed bile duct injuries may present with bile-stained drainage from the incision or a drain, if present.
 

DDx

 

Workup

Approach Considerations

Management depends on patient stability, associated injuries, and imaging findings. If the clinician has a high index of suspicion for concurrent injuries other than a solid organ injury, a diagnostic laparoscopy or exploratory laparotomy may be indicated.  Alternatively, in the rare event that an isolated bile duct injury is suspected on imaging, endoscopic techniques may be favored.

Imaging Studies

Focused assessment with sonography for trauma (FAST) has become a ubiquitous noninvasive extension of the physical examination to assess for fluid in the peritoneal cavity. The etiology of intraperitoneal fluid may not be obvious on FAST; thus, the presence of fluid within the right upper quadrant should be further characterized with either operative exploration or computed tomography (CT). Abdominal sonography is also useful later in the patient’s course to identify perihepatic fluid collections and ascites. 

Abdominal CT can evaluate the right upper quadrant in blunt abdominal trauma cases and is useful to assess for concomitant liver injury. This imaging modality is favored for patients who have significant blunt trauma.

99mTc-Mebrofenin hybrid single photon emission tomography-computed tomography (SPECT-CT) has been shown to be highly sensitive and specific for the detection and localization of posttraumatic bile leaks.[2]  Magnetic resonance cholangiopancreatography (MRCP) is useful for detecting pancreaticobiliary injuries after blunt trauma. HIDA (Tc99m-hepatobiliary iminodiacetic acid) scintigraphy may demonstrate leakage from the biliary tree with progressive accumulation of the tracer in the right upper quadrant or throughout the abdominal cavity.

In stable patients, endoscopic retrograde cholangiopancreatography (ERCP) is extremely useful for the diagnosis of suspected biliary trauma and allows for therapeutic intervention in selected patients.

Procedures

Direct visualization at laparoscopy or laparotomy is the most specific tool to evaluate biliary trauma. Findings may include a contusion to the hepatoduodenal ligament, overlying fresh clot, or active bleeding. Intraoperative cholangiography allows for delineation of anatomy and location of a suspected injury.

Diagnostic peritoneal lavage is mainly of historical interest but may still have a role in very select cases to prioritize management. 

Laboratory Studies

No specific laboratory values exist to diagnose traumatic bile duct injuries. Concurrent liver injuries will likely result in elevated aspartate aminotransferase (AST) and alanine aminotransferase (ALT) levels, which should raise suspicion for a biliary injury. Although not acutely evident, hyperbilirubinemia may develop in undiagnosed injuries secondary to increased bilirubin absorption within the peritoneal cavity.  

 

Treatment

Approach Considerations

The treatment modality of choice depends on patient stability, associated injuries, and imaging findings. If the clinician has a high index of suspicion for concurrent injuries other than a solid organ injury, a diagnostic laparoscopy or exploratory laparotomy may be indicated. Alternatively, in the rare event that an isolated extrahepatic bile duct or gallbladder injury is identified on imaging, endoscopic techniques may be favored.

Consultations

A surgeon or a trauma specialist should have primary responsibility for the care of all patients with biliary injury caused by traumatic mechanisms. A gastroenterologist well versed in endoscopic retrograde cholangiopancreatography (ERCP) techniques is a valuable resource to provide minimally invasive therapies to manage biliary leaks.

Surgical Care

Intrahepatic biliary tract injury

If a distal intrahepatic bile duct injury is observed at surgery, an attempt to ligate it at that time is recommended. After ligation, the duct and surrounding liver parenchyma should be monitored for signs of bile drainage. Larger ducts near the hilum need to be repaired. Occasionally, a partial hepatectomy may even be indicated.

If significant blood is identified on exploration, packing of all 4 quadrants of the abdomen is the initial step. Bleeding from the right upper quadrant that is not controlled by packing may require a Pringle maneuver (compression of the hepatoduodenal ligament), which occludes portal vein and hepatic artery blood flow to the liver. In unstable patients with large liver lacerations and an intrahepatic bile duct injury, damage control should take priority over definitive bile duct management, which can be addressed after the patient has been resuscitated and stabilizes. 

Penetrating extrahepatic biliary tract injury

Patients suspected of having an intra-abdominal injury following a penetrating injury should undergo urgent exploration.   

After proximal and distal control of the hepatoduodenal ligament has been obtained, the edges of the injured bile duct should be debrided to healthy tissue. Circumferential dissection of the common duct should be avoided, if possible, to preserve the vascular supply to the biliary tree.

If the bile duct is completely transected, performing a Roux-en-Y choledochojejunostomy or a choledochoduodenostomy, in a stable patient, is recommended. If the duct is partially transected, primary repair may be possible using absorbable suture. Often a T-tube is placed through a separate site where the bile duct is healthy to provide decompression while the bile duct heals.

If the patient is unstable and cannot tolerate a lengthy operative procedure, a T-tube bridge between the ends of the defect or simple drainage is recommended. To avoid the sequelae of recurrent biliary strictures, definitive repair should be performed when the patient is stabilized.

Blunt extrahepatic biliary tract injury

Management of blunt abdominal trauma is similar to that of penetrating trauma.

As with penetrating injuries, a complete transection to the bile duct often requires either a Roux-en-Y choledochojejunostomy or a choledochoduodenostomy in a stable patient. A T-tube may be used if the duct is partially transected.

A T-tube bridge between the ends of the defect or a simple drain may be required during damage control surgery with the plan for a delayed repair of the bile duct after the patient has been adequately resuscitated.  

Gallbladder injury

Injury to the gallbladder, either from penetrating or blunt injury, is best managed with a cholecystectomy.

Medical Care

Over the past 2 decades, advancements in endoscopic techniques have led to less invasive strategies to manage biliary injuries. Given the rarity of these injuries, only case reports and small case series describe the use of ERCP to manage biliary injuries. In all cases, a biliary stent was placed across the injured duct and a sphincterotomy was often performed.

The successful use of ERCP has been described in both penetrating and blunt trauma.[14, 15, 16]  This strategy has been successful in children as well.[17, 18]  Stents are removed several weeks after the injury, with a fluoroscopic contrast evaluation for a persistent leak or stricture. Although several studies have described the short-term benefit of this strategy, long-term outcomes have not been reported.  

Diet and Activity

Diet

Patients may resume a regular diet after postoperative ileus has resolved. There are no dietary restrictions.

Patients with a complex postoperative course may be fed by a transpyloric feeding tube.

Activity

No activity restrictions are implemented for isolated bile duct system injuries, but restrictions may be necessary for patients with the frequently associated solid organ injury (eg, liver lacerations).

Long-Term Monitoring

Long-term follow-up is important to identify bile duct strictures, which usually occur within 2 years of injury.

A complete metabolic panel, including fractionated bilirubin, alkaline phosphatase (ALP), aspartate aminotransferase (AST), and alanine aminotransferase (ALT) levels, may suggest a post-injury complication.

Endoscopic retrograde cholangiopancreatography (ERCP) or magnetic resonance cholangiopancreatography (MRCP) can be used to assess patients for late extrahepatic biliary tract strictures.