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.
