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:
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Right upper quadrant pain
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Peritonitis
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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:
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Focused assessment with sonography for trauma (FAST): Used to detect fluid in the peritoneal cavity.
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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.
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99mTc-Mebrofenin hybrid single photon emission tomography-computed tomography (SPECT-CT): Used to detect and localize posttraumatic bile leaks. [2]
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Magnetic resonance cholangiopancreatography (MRCP): Useful for detecting pancreaticobiliary injuries after blunt trauma.
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HIDA (Tc 99m-hepatobiliary iminodiacetic acid) scintigraphy: May demonstrate leakage from the biliary tree.
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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:
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Patient stability
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Associated injuries
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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:
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Bilomas
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Strictures
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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.
