You are in: eMedicine Specialties > Medicine, Ob/Gyn, Psychiatry, and Surgery > Trauma
|
Biliary Trauma Last Updated: August 8, 2005 |
|
| Synonyms and related keywords: extrahepatic biliary tract trauma, EBT trauma, gallbladder trauma, GB trauma, biliary tract trauma, EBT, GB
|
| |
AUTHOR INFORMATION
| Section 1 of 9   |
|
| Author: Anastasios K Konstantakos, MD, Fellow, Department of Cardiothoracic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School Coauthor(s): Jeffrey L Ponsky, MD, Chairman, Case Western Reserve University; Professor, Department of Surgery, University Hospitals of Cleveland |
| |
| Editor(s): 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; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine;
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;
Paolo Zamboni, MD, Professor of Surgery, Chief of Day Surgery Unit, Chair of Vascular Diseases Center, University of Ferrara, Italy;
and John Geibel, MD, DSc, MA, 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 |
Disclosure
| |
INTRODUCTION
| Section 2 of 9   |
|
Background: Isolated injury to the extrahepatic biliary tract (EBT) and gallbladder (GB) may occur from a thoracoabdominal injury or an iatrogenic trauma. This discussion considers both blunt trauma and penetrating trauma to the EBT and the GB. This article also covers the impact of laparoscopic cholecystectomy, which has led to an increasing incidence of bile duct injury. Pathophysiology: Typically, a mechanism of crushing or shear injury to the right upper quadrant causes biliary disruption leading to bile peritonitis. The retroduodenal region of the superior portion of the pancreas is the most common site of biliary transection following blunt trauma. The average delay until diagnosis is reportedly 9 days and ranges from hours to 9 months. A perforation or an avulsion of the GB from a blunt thoracoabdominal trauma is extremely rare; penetrating abdominal trauma is a more frequent cause of GB injuries. Frequency:
- In the US: Although the exact incidence of nonoperative biliary trauma is unknown, isolated biliary injury without trauma to associated intra-abdominal structures is extremely rare. Fewer than 40 cases of common bile duct avulsion following blunt trauma are reported; however, it is much more rare than penetrating trauma and more difficult to diagnose.
Mortality/Morbidity:
- Mortality depends directly on the delay in the diagnosis and the treatment, as well as on the severity of the injury.
- Patients with lesions that are promptly discovered and appropriately treated within hours of injury have a mortality rate of less than 10%, while patients with extensive injuries and delayed treatment may have a mortality rate nearing 40%.
Sex: No sexual predilection exists.
Age: Biliary trauma can occur at any age.
History: - Suspect EBT trauma when the patient presents with a mechanism of injury consistent with the application of significant blunt force to the thoracoabdominal region. Mechanisms of injury can range from motor vehicle crashes to short falls.
- Penetrating trauma to the EBT may be obvious based on the external trajectory of the object, especially 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.
- A patient's history of laparoscopic cholecystectomy is an important consideration in defining an EBT injury caused by a prior procedure.
Physical: - Signs of trauma to the EBT caused by thoracoabdominal injury are as follows:
- Early signs of biliary leakage may be difficult to appreciate on physical examination.
- Hypovolemic shock can occur from intense chemical peritonitis when diagnosis is delayed. This can be followed by septic shock from bacterial overgrowth within a period of hours to days; however, with minimal biliary leakage, shock may not occur and abdominal signs may be absent.
- Jaundice is usually observed 3-5 days after injury, along with the passage of clay-colored stools and dark-colored urine.
- Increasing abdominal girth accompanied by signs of dehydration and low-grade sepsis may be observed during the first week after trauma.
- Direct observation with laparoscopy or laparotomy is used to aid in diagnosing penetrating extrahepatic biliary trauma.
- The hepatoduodenal ligament may show contusion, edema, fresh clot formation, or active bleeding.
- Signs of trauma to the EBT caused by operative laparoscopy are as follows:
- Diagnosis of EBT trauma may be made during laparoscopy by direct observation of copious amounts of biliary drainage emanating from the porta hepatis. It may be determined after surgery by patient complaints of abdominal pain, nausea, or increasing abdominal discomfort, occurring during the first week after laparoscopic cholecystectomy.
- Jaundice may also be present.
Causes: - Blunt trauma mechanisms (eg, motor vehicle deceleration injuries, falls, assaults)
- Penetrating injuries caused by a simple direct force (eg, knife wound) or by a complex, indirect injury (eg, gunshot wound)
- Causes of laparoscopic injury to the EBT
- Direct trauma by grasping forceps
- Excessive dissection around the porta hepatis with tearing of the common bile duct wall
- Improper placement of clips lacerating the EBT
- Endoscopic stenting of the biliary tree has led to an increasing incidence of iatrogenic injuries.
| |
DIFFERENTIALS
| Section 4 of 9 |
|
Abdominal Trauma, Blunt
Abdominal Trauma, Penetrating
Abdominal Vascular Injuries
Pancreatic Trauma
Other Problems to be Considered:
Associated injury to the portal vein, the hepatic artery, the pancreas, and the liver |
|
Patient Education
|
|
Click here for patient education.
|
|
|
|
|
Imaging Studies:
- Abdominal CT scanning can evaluate the right upper quadrant in blunt abdominal trauma cases.
- Transabdominal sonography may be useful to observe a bile leak or a dilated common bile duct.
- Endoscopic retrograde cholangiopancreatography (ERCP) may be useful for the diagnosis of suspected, but not obvious, EBT trauma from laparoscopic operation.
- Percutaneous transhepatic cholangiography may also be indicated for delineation of the anatomy in more complicated cases.
- Intraoperative ultrasonography can provide important information by aiding in localization of occult injuries. However, it is highly operator dependent.
- Magnetic resonance cholangiopancreatography (MRCP) has recently been shown to be very useful in detecting pancreaticobiliary injuries after blunt trauma.
Procedures:
- In patients with EBT trauma caused by nonoperative mechanisms (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 EBT, concomitant sphincterotomy of the sphincter of Oddi and possible stenting may be appropriate.
Surgical Care: - 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.
- Perform exploratory surgery on patients with significant penetrating abdominal trauma.
- 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 EBT 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.
- Cholecystectomy is the best treatment for 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 GB 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 EBT.
Further Outpatient Care:
- Long-term follow-up care is important to detect postoperative biliary stricture, which is usually detected within 2 years of repair.
- ERCP can be critical in defining EBT strictures.
| |
MISCELLANEOUS
| Section 8 of 9 |
|
Medical/Legal Pitfalls:
- Failure to promptly diagnose EBT injuries because of the rarity and vague presentation of isolated EBT injury caused by nonoperative mechanisms is a pitfall. The average delay is reportedly 9 days.
- In patients with blunt thoracoabdominal trauma, failure to evaluate associated injuries to the vascular structures within the hepatoduodenal ligament (portal vein and hepatic artery) is a pitfall because these injuries can be life threatening.
- In terms of operative trauma to the EBT, failure to obtain an ERCP to confirm the leak, to identify its site and cause, and to help define a therapeutic plan is a pitfall.
- In minor leaks, endoscopic diversion by sphincterotomy or stenting provides rapid treatment.
- In more significant injuries, ERCP with percutaneous transhepatic cholangiogram often helps assess the extent of injury and determines the strategy for operative repair.
| |
BIBLIOGRAPHY
| Section 9 of 9 |
|
-
Busuttil RW, Kitahama A, Cerise E, et al: Management of blunt and penetrating injuries to the porta hepatis. Ann Surg 1980 May; 191(5): 641-8[Medline].
-
Carmichael DH: Avulsion of the common bile duct by blunt trauma. South Med J 1980 Feb; 73(2): 166-8[Medline].
-
Chi KD, Waxman I: Subcapsular hepatic hematoma after guide wire injury during endoscopic retrograde cholangiopancreatography: management and review. Endoscopy 2004 Nov; 36(11): 1019-21[Medline].
-
Erkan M, Bilge O, Ozden I, et al: Definitive treatment of traumatic biliary injuries. Ulus Travma Derg 2004 Oct; 10(4): 221-5[Medline].
-
Gupta A, Stuhlfaut JW, Fleming KW, et al: Blunt trauma of the pancreas and biliary tract: a multimodality imaging approach to diagnosis. Radiographics 2004 Sep-Oct; 24(5): 1381-95[Medline].
-
Machi J, Oishi AJ, Furumoto NL, Oishi RH: Intraoperative ultrasound. Surg Clin North Am 2004 Aug; 84(4): 1085-111, vi-i[Medline].
-
Ponsky JL: Endoscopic approaches to common bile duct injuries. Surg Clin North Am 1996 Jun; 76(3): 505-13[Medline].
-
Ragozzino A, Manfredi R, Scaglione M, et al: The use of MRCP in the detection of pancreatic injuries after blunt trauma. Emerg Radiol 2003 Apr; 10(1): 14-8[Medline].
-
Shires GT, Thal ER, Jones RC: Trauma. In: Schwartz SI, ed. Principles of Surgery. 6th ed. New York, NY: McGraw-Hill; 1994: 175-224.
-
Sriram PV, Ramakrishnan A, Rao GV, et al: Spontaneous fracture of a biliary self-expanding metal stent. Endoscopy 2004 Nov; 36(11): 1035-6[Medline].
Biliary Trauma excerpt |
){kind=small}