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Biliary Trauma

Published on 19/07/2015 by admin

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 Pericholecystic free fluid, intraluminal or pericholecystic hematoma, or GB wall thickening

image Poor definition of GB wall, abnormal GB contour, or collapsed GB, particularly with surrounding pericholecystic fluid, suggest GB perforation
image Unusual positioning of GB or separation of GB from normal location in GB fossa suggests GB avulsion
• Bile duct injuries

image Can include tears, transections, or ligations, and may be associated with bile leaks
image Free fluid or loculated collections (bilomas) in the right upper quadrant adjacent to biliary tree
image Proximal biliary dilatation with abrupt narrowing of duct at site of bile duct laceration or stricture
image MR hepatobiliary contrast agents (e.g., Eovist) can be utilized to directly visualize leak or stricture
image Tc-99m hepatobiliary scintigraphy very sensitive for both bile leaks and biliary obstruction
image Bile leaks may be identified as sites of active contrast extravasation on cholangiography

CLINICAL ISSUES

• Trauma-related injuries to biliary tree are rare, accounting for only 0.1% of all trauma admissions
• Iatrogenic injuries more common, with ∼ 2,500 bile duct injuries during cholecystectomy in United States
• Gallbladder injuries treated with cholecystectomy
• Minor bile duct injuries treated conservatively with stent placement or drainage catheter
• More severe injuries require surgical treatment (usually Roux-en-Y hepaticojejunostomy)
image
(Left) Axial CECT shows hematoma image separating the gallbladder image from its normal location in the gallbladder fossa. The patient was taken to surgery where the gallbladder was found to be “avulsed” from its hepatic attachment and leaking bile.

image
(Right) ERCP in a patient after cholecystectomy demonstrates a high-grade biliary stricture image immediately adjacent to a surgical clip image, in keeping with an iatrogenic stricture. The stricture in this case ultimately required hepaticojejunostomy.
image
(Left) Axial CECT in a patient after blunt trauma demonstrates a deep liver laceration image and small hemoperitoneum. The depth of the laceration raised concern for biliary transection. The patient developed signs of bile peritonitis.

image
(Right) ERCP in the same patient shows extravasation of contrast from a transected bile duct image. The patient was successfully treated with biliary stenting without surgery. The biliary and hepatic injuries resolved.

TERMINOLOGY

Synonyms

• Bile duct injury

Definitions

• Hemobilia: Bleeding into biliary tract
• Bilhemia: Rare condition in which bile enters veins of liver

IMAGING

General Features

• Best diagnostic clue

image  
• Location

image Trauma: Most common site of injury is gallbladder (GB)

– Injuries to intrahepatic ducts usually occur with concomitant liver injury, while extrahepatic bile duct injuries most frequently involve common bile duct/hepatic duct
image Postoperative injuries: Common hepatic duct (45-64%) and hepatic hilum (20-33%) most common locations

– Most common injury is common duct transection (common duct mistaken for cystic duct during cholecystectomy)
– Postoperative bile leaks usually arise from cystic duct stump, duct of Luschka (accessory duct in right hepatic lobe that traverses GB fossa), and GB bed
–  
image Biliary fistulas: Internal (communication with duodenum, colon, bronchi, etc.) or external (skin)

– Biliary-vascular fistulas: To portal vein, hepatic artery, hepatic veins
• Size

image Focal or diffuse involvement
• Morphology

image Bile leakage, strictures, biliary tree obstruction, various types of biliary fistulas, hemobilia

Radiographic Findings

• Radiography

image Biliary-enteric fistula: Pneumobilia
• ERCP

image Can facilitate definitive diagnosis and treatment of bile leaks and simple strictures
image Bile leaks may be identified as sites of active contrast extravasation

– ERCP can define site of leak in 95% of cases
image Post-traumatic strictures typically focal, smooth areas of narrowing with proximal dilation
image Percutaneous transhepatic cholangiography (PTC) may be required in cases of severe extrahepatic duct stricture to fully evaluate intrahepatic biliary tree or more proximal extrahepatic duct
image Visualization and cannulation of fistula orifice; permits good quality cholangiographic evaluation
image May see active bleeding at major papilla

– PTC is also much more sensitive for injuries to ducts in segments VI and VII (often poorly evaluated on ERCP)

Fluoroscopic Findings

• Biliary-enteric fistula: Barium filling of biliary tree

image Nonionic or oil-based contrast material is indicated when biliary-bronchial fistula is suspected

CT Findings

• Gallbladder injury

image Imaging findings may vary depending on degree of injury, and some mild gallbladder contusions may be invisible on imaging
image Presence of pericholecystic free fluid, intraluminal or pericholecystic high-density hematoma, or gallbladder wall thickening should raise concern for injury
image Poor definition of gallbladder wall (i.e., sites of nonenhancement), abnormal GB contour, or collapsed GB, particularly with surrounding pericholecystic fluid, raises suspicion for GB perforation
image Active extravasation may rarely be seen within GB lumen (most evident on arterial phase images)
image Unusual positioning of GB or separation of GB from normal location in GB fossa in cases of avulsion
image Suspect GB injury if liver laceration extends into GB fossa
• Bile duct injuries

image Free fluid or loculated collections (bilomas) in right upper quadrant (either intra- or extrahepatic) adjacent to biliary tree

– CT cannot differentiate bilomas from other common post-traumatic and postsurgical fluid collections (hematomas, seromas, lymphocele, abscess)
– CT cannot accurately define site of leak (although location of biloma may be suggestive)
image Proximal biliary dilatation with abrupt narrowing of duct at site of bile duct laceration or stricture
image Biliary-enteric fistula: Oral contrast visible in both bowel and biliary tree
• Helical CT cholangiography (after IV administration of biliary contrast material) to verify and localize bile duct leakage

image May help avoid ERCP
• Can demonstrate extent and localization of parenchymal destruction in bilio-vascular fistula
• Presence of biliary dilatation, configuration of injured bile duct, and ancillary abdominal findings
• Hemobilia: Blood may appear as high-attenuation material (> 50 HU) in ducts or gallbladder

image Liver laceration, hematoma, other potential sources of blood may also be detected
• CT-guided drainage; nonoperative management of parenchymal and perihepatic fluid collections

MR Findings

• Hepatobiliary contrast agents (e.g., Eovist) can be utilized to directly visualize leak or stricture

image Contrast is excreted into biliary tree in delayed hepatobiliary phase (15-30 minutes), creating MR cholangiogram
image Active extravasation of contrast in cases of bile leaks/lacerations

– Sensitivity for bile leaks may be as high as 95%
image May allow better definition of strictures or bile duct narrowing compared to conventional MRCP
• Conventional MRCP can define sites of stricture or narrowing in biliary tree but cannot accurately define exact site of bile leak

Ultrasonographic Findings

• Proximal biliary dilation with gradual tapering of duct diameter and no surrounding mass present
• Bilomas are usually anechoic, well-marginated fluid collections (some internal low-level echoes possible in setting of superinfection or associated hemorrhage)
• Echogenic material in bile ducts or gallbladder should suggest hemobilia
• Ultrasound-guided drainage of collections

Angiographic Findings

• Hemobilia: Diagnosis most commonly confirmed by selective hepatic arteriography, demonstrating extravasation of contrast material into biliary tree

image Depicts or excludes hepatic artery aneurysm/pseudoaneurysm (causes 10% of biliary bleeding cases)
image Facilitates embolic occlusion therapy
• If vessel injury or hemobilia suspected on CT scan, angiography should be performed

image Can be therapeutic, thereby avoiding surgery

Nuclear Medicine Findings

• Tc-99m hepatobiliary scintigraphy is very sensitive for both bile leaks and biliary obstruction

image Accumulation of radiotracer outside of normal confines of biliary tree suggests leak
image Sensitivity for bile leaks may approach 100% but is not accurate for defining exact site of leak or severity of injury (i.e., transection vs. partial tear)
• Hepatobiliary scintigraphy also a safe means of investigating possible biliary-bronchial fistula

Other Modality Findings

• Cholangiography: May demonstrate clotted blood as cast-like filling defect in bile ducts

image May reveal other potential causes of hemorrhage

Imaging Recommendations

• Best imaging tool

image Percutaneous transhepatic cholangiography (PTC) or ERCP: Gold standard for diagnosis of bile duct injuries
image PTC is generally more valuable than ERCP: Defines anatomy of proximal biliary tree to be used in surgical reconstruction
• Protocol advice

image ERCP, PTC, MRCP, angiography

DIFFERENTIAL DIAGNOSIS

Biliary Stricture Due to Nontraumatic Causes

• Pancreatic ductal carcinoma

image Pancreatic mass with pancreatic atrophy and pancreatic ductal dilatation
image No history of trauma or surgery
• Cholangiocarcinoma

image Small mass with abrupt biliary obstruction at confluence of right and left ducts or at common duct
image No history of trauma or surgery
• Primary sclerosing cholangitis

image Multifocal “beaded” strictures with alternating sites of stricture, normal ducts, and mildly dilated ducts
image No history of trauma or surgery

PATHOLOGY

General Features

• Etiology

image Trauma: Can result from blunt or penetrating injuries

– Tend to result from significant trauma with other injuries frequent (especially liver, spleen, and duodenum)
– Most commonly injured site in biliary tree is GB 

image GB injuries range in severity, including contusion, laceration, perforation, and GB avulsion (separation of GB from GB fossa)
image Isolated injury to GB rare due to protection from rib cage and liver, so almost always associated with other significant traumatic injuries
image Most common when GB is distended or after alcohol intake (distends GB by raising pressures at sphincter of Oddi)
image GB wall thickening or gallstones thought to be possibly protective
image GB ischemia and perforation due to traumatic arterial injury reported (very rare)
– Injuries to intrahepatic ducts most common with liver lacerations
image Iatrogenic

– Most commonly after laparoscopic or open cholecystectomy
– Other common sources of injury include 

image Percutaneous liver biopsy or catheter placement
image Biliary tract exploration at surgery or ERCP
image Other upper abdominal operations (e.g., hepatic resection, gastrectomy)
image Hepatic artery chemoembolization (e.g., for hepatic metastases or primary carcinoma)
– Iatrogenic injury occurs as result of technical errors or misidentification of biliary anatomy

image More common in setting of surgeon inexperience, cholecystitis, and aberrant anatomy
image Debate whether routine cholangiography prior to cholecystectomy may reduce biliary injuries
– Injuries can include tears, transections, or ligations, and may be associated with bile leaks
image Following liver transplantation

– 3 main types/sites of biliary leaks

image T-tube entry to recipient duct (treated with temporary biliary stent)
image Biliary anastomosis (may require surgical revision)
image Intrahepatic (donor) ducts (usually sign of ischemic biliary necrosis)

Staging, Grading, & Classification

• Strasberg classification most widely utilized to guide management

image Type A: Leaks from minor duct (i.e., cystic duct or gallbladder fossa biliary radicle) in contiguity with CBD
image Type B: Occlusion of injured right accessory duct still in contiguity with biliary tree
image Type C: Bile leak from injured right accessory duct no longer in contiguity with biliary tree
image Type D: Bile leak from common duct with no loss of continuity with rest of biliary tree
image Type E: Complete transection of bile duct

Gross Pathologic & Surgical Features

• Post-laparoscopic cholecystectomy

image Spectrum of injury ranges from cystic duct stump leakage to complete transection or obstruction of common hepatic duct

Microscopic Features

• Disruption of duct epithelium, communication between ducts and other organs, narrowing of lumen

CLINICAL ISSUES

Presentation

• Most common signs/symptoms

image Virtually all patients with traumatic bile duct injury have other significant injuries that require attention

– Many patients with biliary strictures or bile leaks after blunt abdominal trauma may have delayed onset of symptoms, or symptoms may be attributed to other concomitant injuries
– Symptoms may present days to weeks after initial trauma
– Presentation may be due to obstructive jaundice, persistently elevated or rising bilirubin, or bile peritonitis
image Postoperative bile duct injuries: May present early with obstructive jaundice or evidence of bile leak

– In patients presenting months to years after surgery due to stricture, cholangitis is most common symptom
– Complications recognized in 10-25% of patients with post-cholecystectomy injuries within 1st week

image Recognized in ∼ 70% of patients within 1-6 months
image Hemobilia: Triad of GI blood loss, biliary colic, and jaundice
• Clinical profile

image Lab data: Excessively high serum level of direct bilirubin and only moderately elevated liver enzymes indicate bilhemia in trauma patients
image Thoracentesis: Presence of bile in pleural cavity considered proof of pleural-biliary fistula

Demographics

• Age

image Iatrogenic and traumatic injuries more common in adults
• Gender

image Males: More likely to suffer traumatic injuries
image Females: More iatrogenic injuries due to more frequent cholecystectomies
• Epidemiology

image Trauma-related injuries to biliary tree are rare, accounting for only 0.1% of all trauma admissions

– 50% of cases of hemobilia due to blunt trauma
image Iatrogenic injuries more common, with ∼ 2,500 bile duct injuries after cholecystectomy in United States

– ↑ incidence over past decade with introduction of laparoscopic cholecystectomy

image Biliary injuries with laparoscopic cholecystectomy 2x more common than with open technique
image 95% of strictures are secondary to surgical injury and > 80% from trauma during cholecystectomy

Natural History & Prognosis

• Major, profuse hemobilia is rare, but it may be life-threatening; minor hemobilia is more frequent and often clinically silent

image Bleeding may often be delayed by 3-4 weeks or even as much as 12 weeks after liver injury
• Biliary cirrhosis from longstanding obstruction
• Significant morbidity and mortality associated with nonsurgical trauma to extrahepatic biliary tract

Treatment

• Traumatic GB injuries treated with cholecystectomy
• Injuries detected intraoperatively during cholecystectomy should be repaired immediately
• Minor bile duct injuries (including many intrahepatic ductal injuries) usually treated conservatively with ERCP stent placement or biliary drainage catheter to divert bile away from site of injury and allow time for healing

image Placement of drainage catheter into any adjacent bilomas
• More severe injuries require surgical treatment (usually Roux-en-Y hepaticojejunostomy) after ERCP (or PTC) to assess injury and plan operative repair
• Hemobilia: Conservatively treated if minor bleeding, but more severe hemobilia may require embolization or surgery
• Bile duct fistula: Spontaneous closure, suture of fistula and T-tube drainage, decompression

DIAGNOSTIC CHECKLIST

Consider

• High index of suspicion is mandatory in patients complaining of discomfort several days after surgery
• Patients with major bile duct injuries should be evaluated for concomitant hepatic arterial injury
image
(Left) Cholangiogram in a patient after cholecystectomy demonstrates complete obstruction and contrast extravasation from the common hepatic duct image, immediately adjacent to surgical clips, in keeping with an iatrogenic bile duct transection.

image
(Right) Tc-99m HIDA scan shows foci of radiotracer accumulation image outside of the biliary tree due to bile extravasation in a patient who had prior blunt trauma. HIDA scans are very sensitive and specific for bile leaks.
image
(Left) Axial CECT in a patient who had undergone recent cholecystectomy shows a large, loculated fluid collection image in the gallbladder fossa, subsequently confirmed to be a biloma based on ultrasound-guided needle aspiration.

image
(Right) ERCP in the same patient confirms extravasation of bile image from the cystic duct remnant. Sphincterotomy was performed, and a plastic biliary stent was placed. The bile leak resolved, and the stent was removed subsequently without complication.
image
(Left) Axial CECT in a trauma patient shows a liver laceration image and intraperitoneal free fluid. There is heterogeneous fluid and hematoma around the pancreatic head image, near the expected position of the common bile duct.

image
(Right) The same patient developed progressive abdominal pain and clinical signs suggestive of peritonitis. Concern about biliary injury prompted transhepatic cholangiography, which showed transection of the distal common bile duct within the pancreatic head, and extravasation of bile image.
image
Axial CECT shows pericholecystic hematoma image with subtle active extravasation image of blood immediately adjacent to the gallbladder fossa. The gallbladder itself appears normally distended, suggesting that it is intact. At surgery, the gallbladder itself was intact, but it was “avulsed” from its hepatic attachments, which were the source of the active bleeding.

image
Axial NECT of a 53-year-old man with severe right upper quadrant pain and jaundice 2 days post liver biopsy shows subtle high-attenuation clot within a slightly dilated distal common duct image. The patient’s clinical history and the absence of hemoperitoneum strongly suggests a bile duct injury and hemobilia.
image
ERCP of the same patient shows filling defect compatible with extensive clot image within a slightly dilated common duct. The patient’s symptoms resolved after sphincterotomy and clot retrieval.
image
CECT in a patient with a post-cholecystectomy biliary stricture shows marked intrahepatic biliary ductal dilatation image. ERCP (not shown) demonstrated a high-grade stricture adjacent to a clip. Post-cholecystectomy strictures may require surgical biliary diversion.
image
Ultrasound of a 52-year-old woman with severe abdominal pain and hematemesis performed 3 days post liver biopsy shows echogenic clot within a dilated common image and right bile duct image. Clot was also shown within the gallbladder.
image
Catheter angiography performed in the same patient shows a right hepatic artery to bile duct fistula, evidenced by early and prolonged enhancement of a distal bile duct image. The fistula was successfully treated with coil embolization.
image
CECT of a 19-year-old woman with bile peritonitis post laparotomy for a gunshot wound to the lateral segment image shows perihepatic bile image. Note the mild mass effect upon the liver and extensive fluid within the lesser sac image.
image
ERCP of the same patient performed after placement of a left perihepatic space drain image shows a distal left bile duct injury and extravasated contrast image. The leak was treated successfully with perihepatic drainage and left bile duct stent placement.
image
Axial CECT in a trauma patient hemobilia demonstrates a large liver laceration image with a spherical intrahepatic pseudoaneurysm image. Endoscopy confirmed blood entering the duodenum via the ampulla of Vater, indicating hemobilia.
image
Angiography in the same patient confirms the hepatic pseudoaneurysm image, which was occluded by coil embolization. The hemobilia also ceased following embolization.

SELECTED REFERENCES

1. Melamud, K, et al. Biliary imaging: multimodality approach to imaging of biliary injuries and their complications. Radiographics. 2014; 34(3):613–623.

 

Hommes, M, et al. Management of biliary complications in 412 patients with liver injuries. J Trauma Acute Care Surg. 2014; 77(3):448–451.

Mbarushimana, S, et al. CT diagnosis of an iatrogenic bile duct injury. BMJ Case Rep. 2014, 2014.

Stewart, L. Iatrogenic biliary injuries: identification, classification, and management. Surg Clin North Am. 2014; 94(2):297–310.

Mercado, MA, et al. Classification and management of bile duct injuries. World J Gastrointest Surg. 2011; 3(4):43–48.

Shah, PA, et al. Hepatic gas: widening spectrum of causes detected at CT and US in the interventional era. Radiographics. 2011; 31(5):1403–1413.

Chin, MW, et al. Hemobilia. Curr Gastroenterol Rep. 2010; 12(2):121–129.

Pawa, S, et al. ERCP in the management of biliary complications after cholecystectomy. Curr Gastroenterol Rep. 2009; 11(2):160–166.

Hoeffel, C, et al. Normal and pathologic features of the postoperative biliary tract at 3D MR cholangiopancreatography and MR imaging. Radiographics. 2006; 26(6):1603–1620.

Familiari, L, et al. An endoscopic approach to the management of surgical bile duct injuries: nine years’ experience. Dig Liver Dis. 2003; 35(7):493–497.

Federle, MP, et al. Complications of liver transplantation: imaging and intervention. Radiol Clin North Am. 2003; 41(6):1289–1305.

Goffette, PP, et al. Traumatic injuries: imaging and intervention in post-traumatic complications (delayed intervention). Eur Radiol. 2002; 12(5):994–1021.

Wong, YC, et al. Magnetic resonance imaging of extrahepatic bile duct disruption. Eur Radiol. 2002; 12(10):2488–2490.

Green, MH, et al. Haemobilia. Br J Surg. 2001; 88(6):773–786.

Yoon, KH, et al. Biliary stricture caused by blunt abdominal trauma: clinical and radiologic features in five patients. Radiology. 1998; 207(3):737–741.

Slanetz, PJ, et al. Imaging and interventional radiology in laparoscopic injuries to the gallbladder and biliary system. Radiology. 1996; 201(3):595–603.

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