Isolated extrahepatic biliary tract injury following blunt abdominal trauma is rare. The underlying pathogenic mechanisms remain obscure, but include shear and/or compression forces on the biliary system. Associated morbidity rates are high and largely the result of delays in diagnosis. Imaging modalities commonly employed for diagnosis include ultrasonography, computed tomography, nuclear medicine, and magnetic resonance imaging. Percutaneous and endoscopic techniques have been used both for diagnosis and treatment. Treatment options are dictated by the stability of the patient and the extent of bile duct and concomitant injuries. In this paper, we discuss a case of isolated avulsion of the hepatic duct confluence following blunt trauma that was successfully managed with Roux-en-Y hepaticojejunostomy. To our knowledge, this specific injury pattern has not been previously reported.
Isolated biliary tract injury following blunt abdominal injury is extremely rare [
A 45-year-old man sustained blunt compression injury to his abdomen while working under a van. He was immediately extricated and presented at a referring hospital 24 hours later with mild abdominal fullness and pain. Upon transfer to our hospital, he had developed worsening abdominal pain and one episode of nonbilious emesis. He was tachycardic (120 beats/min) with mildly elevated blood pressure (140/80). His abdomen was distended, diffusely tender; and without signs of external trauma. Abnormal laboratory studies included WBC 19×103/
Coronal CT image demonstrating intraabdominal fluid above the liver and along the right pericolic gutter (arrows). “Periportal tracking” is also present (arrowhead), suggestive of an extrahepatic biliary injury. Possible disruption of the extrahepatic bile duct is visualized.
Exploration revealed bilious fluid that tracked into the right pericolic gutter and retroperitoneum. No injuries were detected in any solid organs or hollow viscera. Medial rotation of the right colon and duodenum did not reveal injuries in the lesser sac or retroperitoneum. The hepatic hilum was bile stained and dissection of the hepatoduodenal ligament demonstrated complete avulsion of the hepatic duct at the confluence. The left hepatic duct and the right posterior and anterior duct junctions were visualized (Figure
Intraoperative photograph (a) and schematic (b) demonstrating isolated avulsion of the hepatic duct confluence. The right anterior and posterior hepatic ducts (arrowhead), left hepatic duct (arrow), and common hepatic duct (asterisk) are visualized.
Although isolated bile duct injuries have been described, isolated avulsion of the common hepatic duct confluence following blunt trauma has not been previously reported. Extrahepatic biliary tract injury after blunt trauma is exceedingly rare and often associated with injuries in adjacent organs [
Several mechanisms have been proposed for blunt injury of the extrahepatic biliary system. These can be grouped into three categories: (1) crushing against the rigid spinal column, (2) shearing against areas of relative fixation, and (3) rapid emptying of a distended gallbladder into the bile ducts.
Our patient had a prior laparoscopic cholecystectomy, suggesting that rapid compression of a filled gallbladder is not an essential factor in injuries of this type. Another hypothesis proposes that shearing forces lift the liver superiorly while the hepatoduodenal ligament is pulled inferiorly [
Diagnostic investigations commonly reported include ultrasonography and CT imaging [
Surgical options for extrahepatic ductal injuries depend on the stability of the patient [
To our knowledge, isolated avulsion of the hepatic duct confluence following blunt abdominal compression injury has not been previously reported. A high index of suspicion is critical to effectively identify and manage these injuries. Upon diagnosis, treatment is dictated by the hemodynamic stability of the patient and the extent of injury. Although various endoscopic, percutaneous, and surgical options are available, biliary-enteric reconstruction provides the best long term outcome for major injuries to the extrahepatic biliary system.
The authors declare that there is no conflict of interests.
Written informed consent was obtained from the patient.