Pericholecystic free fluid, intraluminal or pericholecystic hematoma, or GB wall thickening
Poor definition of GB wall, abnormal GB contour, or collapsed GB, particularly with surrounding pericholecystic fluid, suggest GB perforation
Unusual positioning of GB or separation of GB from normal location in GB fossa suggests GB avulsion
• Bile duct injuries
Can include tears, transections, or ligations, and may be associated with bile leaks
Free fluid or loculated collections (bilomas) in the right upper quadrant adjacent to biliary tree
Proximal biliary dilatation with abrupt narrowing of duct at site of bile duct laceration or stricture
MR hepatobiliary contrast agents (e.g., Eovist) can be utilized to directly visualize leak or stricture
Tc-99m hepatobiliary scintigraphy very sensitive for both bile leaks and biliary obstruction
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)
(Left) Axial CECT shows hematoma separating the gallbladder 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.
(Right) ERCP in a patient after cholecystectomy demonstrates a high-grade biliary stricture immediately adjacent to a surgical clip , in keeping with an iatrogenic stricture. The stricture in this case ultimately required hepaticojejunostomy.
(Left) Axial CECT in a patient after blunt trauma demonstrates a deep liver laceration and small hemoperitoneum. The depth of the laceration raised concern for biliary transection. The patient developed signs of bile peritonitis.
(Right) ERCP in the same patient shows extravasation of contrast from a transected bile duct . 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
• Location
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
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
–
Biliary fistulas: Internal (communication with duodenum, colon, bronchi, etc.) or external (skin)
– Biliary-vascular fistulas: To portal vein, hepatic artery, hepatic veins
• Size
Focal or diffuse involvement
• Morphology
Bile leakage, strictures, biliary tree obstruction, various types of biliary fistulas, hemobilia
Radiographic Findings
• Radiography
Biliary-enteric fistula: Pneumobilia
• ERCP
Can facilitate definitive diagnosis and treatment of bile leaks and simple strictures
Bile leaks may be identified as sites of active contrast extravasation
– ERCP can define site of leak in 95% of cases
Post-traumatic strictures typically focal, smooth areas of narrowing with proximal dilation
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
Visualization and cannulation of fistula orifice; permits good quality cholangiographic evaluation
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
Nonionic or oil-based contrast material is indicated when biliary-bronchial fistula is suspected
CT Findings
• Gallbladder injury
Imaging findings may vary depending on degree of injury, and some mild gallbladder contusions may be invisible on imaging
Presence of pericholecystic free fluid, intraluminal or pericholecystic high-density hematoma, or gallbladder wall thickening should raise concern for injury
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
Active extravasation may rarely be seen within GB lumen (most evident on arterial phase images)
Unusual positioning of GB or separation of GB from normal location in GB fossa in cases of avulsion
Suspect GB injury if liver laceration extends into GB fossa
• Bile duct injuries
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)
Proximal biliary dilatation with abrupt narrowing of duct at site of bile duct laceration or stricture
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
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
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
Contrast is excreted into biliary tree in delayed hepatobiliary phase (15-30 minutes), creating MR cholangiogram
Active extravasation of contrast in cases of bile leaks/lacerations
– Sensitivity for bile leaks may be as high as 95%
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
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Poor definition of GB wall, abnormal GB contour, or collapsed GB, particularly with surrounding pericholecystic fluid, suggest GB perforation
Proximal biliary dilatation with abrupt narrowing of duct at site of bile duct laceration or stricture
separating the gallbladder 
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.
immediately adjacent to a surgical clip 
, in keeping with an iatrogenic stricture. The stricture in this case ultimately required hepaticojejunostomy.
and small hemoperitoneum. The depth of the laceration raised concern for biliary transection. The patient developed signs of bile peritonitis.
. The patient was successfully treated with biliary stenting without surgery. The biliary and hepatic injuries resolved.
Postoperative injuries: Common hepatic duct (45-64%) and hepatic hilum (20-33%) most common locations
Imaging findings may vary depending on degree of injury, and some mild gallbladder contusions may be invisible on imaging
Presence of pericholecystic free fluid, intraluminal or pericholecystic high-density hematoma, or gallbladder wall thickening should raise concern for injury
Free fluid or loculated collections (bilomas) in right upper quadrant (either intra- or extrahepatic) adjacent to biliary tree
