Biliary Trauma Workup

Updated: Jun 09, 2017
  • Author: Frederick Merrill Karrer, MD, FACS; Chief Editor: John Geibel, MD, DSc, MSc, AGAF  more...
  • Print

Imaging Studies

See the list below:

  • Transabdominal sonography is useful to observe perihepatic fluid collections, ascites and/or a dilated biliary tree (intra- and/or extrahepatic).
  • HIDA (Tc 99m - 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 abdomen.
  • Abdominal CT scanning can evaluate the right upper quadrant in blunt abdominal trauma cases and may be helpful in assesses for concomitant hepatic artery injury in the cases of iatrogenic biliary injuries.
  • Endoscopic retrograde cholangiopancreatography (ERCP), in stable patients, is useful for the diagnosis of suspected extrahepatic biliary tract trauma and allows for therapeutic intervention in selected patients.
  • Magnetic resonance cholangiopancreatography (MRCP) has been shown to be useful in detecting pancreaticobiliary injuries after blunt trauma.
  • Percutaneous transhepatic cholangiography may also be indicated for delineation of the anatomy in more complicated cases, particularly in cases with intrahepatic biliary dilation.
  • Intraoperative ultrasonography can provide important information by aiding in localization of occult injuries. However, it is highly operator dependent.
  • Intraoperative cholangiography, if time and patient stability allow, allows for delineation of anatomy and diagnosis of a suspected injury.
  • 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 postoperative and posttraumatic bile leaks. [3]


See the list below:

  • 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.


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. [4]

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) [5] (Open Table in a new window)

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) [5] (Open Table in a new window)

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) [5] (Open Table in a new window)

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 Additional Classification Systems [5] (Open Table in a new window)

Classification System Year Types
Amsterdam Academic Medical Center’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
Chinese University of Hong Kong (CUHK) classification 2007 1-5