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Isolated extrahepatic bile duct rupture in blunt abdominal trauma

      To the Editor,
      Single lesion of the main bile duct in closed abdominal trauma is an uncommon event [
      • Parks R.W.
      • Diamond T.
      Non-surgical trauma to the extrahepatic biliary tract.
      ], usually produced in patients with severe abdominal trauma involving several organs [
      • Parks R.W.
      • Diamond T.
      Non-surgical trauma to the extrahepatic biliary tract.
      ,
      • Sondenaa K.
      • Horn A.
      • Nedrebo T.
      Diagnosis of blunt trauma to the gallbladder and bile ducts.
      ,
      • Revuelta S.
      • Lopez F.
      • Ortiz R.
      • Fernandez C.
      Lesiones biliares extrahepáticas en el traumatismo abdominal.
      ,
      • Melton S.M.
      • McGwin G.
      • Cross J.M.
      • Davidson J.
      • Waller H.
      • et al.
      Common bile duct transection in blunt abdominal trauma: case report emphasizing mechanism of injury and therapeutic management.
      ,
      • Rodriguez Montes J.A.
      • Rojo E.
      • Martín L.G.
      Complications following repair of extrahepatic bile duct injuries after blunt abdominal trauma.
      ]. The diagnosis is difficult unless obtained immediately in a laparotomy performed for another indication [
      • Parks R.W.
      • Diamond T.
      Non-surgical trauma to the extrahepatic biliary tract.
      ,
      • Sondenaa K.
      • Horn A.
      • Nedrebo T.
      Diagnosis of blunt trauma to the gallbladder and bile ducts.
      ,
      • Revuelta S.
      • Lopez F.
      • Ortiz R.
      • Fernandez C.
      Lesiones biliares extrahepáticas en el traumatismo abdominal.
      ,
      • Melton S.M.
      • McGwin G.
      • Cross J.M.
      • Davidson J.
      • Waller H.
      • et al.
      Common bile duct transection in blunt abdominal trauma: case report emphasizing mechanism of injury and therapeutic management.
      ,
      • Rodriguez Montes J.A.
      • Rojo E.
      • Martín L.G.
      Complications following repair of extrahepatic bile duct injuries after blunt abdominal trauma.
      ]. We present a new case and discuss the injury mechanisms, diagnostic methods, and different therapies that can be applied.
      We present the case of a 36-year-old woman with a history of appendectomy, cholecystectomy (1997), residual choledocholithiasis resolved by endoscopic retrograde cholangiopancreatography, and a biliary prosthesis (2000, subsequently withdrawn). She arrived at the hospital after an accidental fall in her bath with a blow to the anterior abdominal wall, especially the right side. She reported abdominal pain and nausea, without vomiting. At the examination, she was conscious, oriented (GCS of 15), and hemodynamically stable (BP, 130/90 mm Hg). The abdomen was soft with no peritonism. Laboratory results were unremarkable except for hemoglobin (16.7 mg/dL). Abdominopelvic computed tomography scan showed free subhepatic liquid in the right abdomen and vesicorectal space, with no injuries to the spleen, liver, or renal parenchyma. At 12 hours, she presented with peritonism and a surgical exploration was carried out, revealing biliary peritonitis secondary to rupture of the anterior surface of the middle third of the extrahepatic bile duct Fig. 1. The bile duct rupture was closed, and a Kehr tube was inserted at 2 cm from the rupture. The postoperative course was satisfactory. The Kehr tube was withdrawn at 20 days after the surgery.
      Figure thumbnail gr1
      Fig. 1Black arrow shows an orifice in extrahepatic bile duct.
      Lesions of the extrahepatic bile duct and/or gallbladder are produced in 1% to 5% of abdominal trauma [
      • Parks R.W.
      • Diamond T.
      Non-surgical trauma to the extrahepatic biliary tract.
      ], and 85% of these are penetrating trauma, usually knife or gunshot wounds [
      • Parks R.W.
      • Diamond T.
      Non-surgical trauma to the extrahepatic biliary tract.
      ,
      • Sondenaa K.
      • Horn A.
      • Nedrebo T.
      Diagnosis of blunt trauma to the gallbladder and bile ducts.
      ,
      • Revuelta S.
      • Lopez F.
      • Ortiz R.
      • Fernandez C.
      Lesiones biliares extrahepáticas en el traumatismo abdominal.
      ,
      • Melton S.M.
      • McGwin G.
      • Cross J.M.
      • Davidson J.
      • Waller H.
      • et al.
      Common bile duct transection in blunt abdominal trauma: case report emphasizing mechanism of injury and therapeutic management.
      ,
      • Rodriguez Montes J.A.
      • Rojo E.
      • Martín L.G.
      Complications following repair of extrahepatic bile duct injuries after blunt abdominal trauma.
      ]. The gallbladder is injured in 85% of these patients, whereas injury of the main bile duct alone occurs in 15% (ie, 0.3%-0.5% of patients with abdominal trauma). It is more frequent in young males [
      • Parks R.W.
      • Diamond T.
      Non-surgical trauma to the extrahepatic biliary tract.
      ]. The parts of the main bile duct that are attached to other abdominal structures are the most susceptible to injury: bifurcation of the hepatic ducts and intrapancreatic bile duct [
      • Parks R.W.
      • Diamond T.
      Non-surgical trauma to the extrahepatic biliary tract.
      ,
      • Sondenaa K.
      • Horn A.
      • Nedrebo T.
      Diagnosis of blunt trauma to the gallbladder and bile ducts.
      ,
      • Revuelta S.
      • Lopez F.
      • Ortiz R.
      • Fernandez C.
      Lesiones biliares extrahepáticas en el traumatismo abdominal.
      ,
      • Melton S.M.
      • McGwin G.
      • Cross J.M.
      • Davidson J.
      • Waller H.
      • et al.
      Common bile duct transection in blunt abdominal trauma: case report emphasizing mechanism of injury and therapeutic management.
      ,
      • Rodriguez Montes J.A.
      • Rojo E.
      • Martín L.G.
      Complications following repair of extrahepatic bile duct injuries after blunt abdominal trauma.
      ]. Main bile duct lesions are commonly associated with severe abdominal injuries. The liver is injured in 50% to 80% of cases [
      • Parks R.W.
      • Diamond T.
      Non-surgical trauma to the extrahepatic biliary tract.
      ,
      • Melton S.M.
      • McGwin G.
      • Cross J.M.
      • Davidson J.
      • Waller H.
      • et al.
      Common bile duct transection in blunt abdominal trauma: case report emphasizing mechanism of injury and therapeutic management.
      ].
      Bile duct lesions due to blunt trauma are produced by traffic accidents (compression by safety belt or airbag) [
      • Melton S.M.
      • McGwin G.
      • Cross J.M.
      • Davidson J.
      • Waller H.
      • et al.
      Common bile duct transection in blunt abdominal trauma: case report emphasizing mechanism of injury and therapeutic management.
      ] and also by falls, kicks, or work accidents [
      • Parks R.W.
      • Diamond T.
      Non-surgical trauma to the extrahepatic biliary tract.
      ,
      • Sondenaa K.
      • Horn A.
      • Nedrebo T.
      Diagnosis of blunt trauma to the gallbladder and bile ducts.
      ] Their origin is currently considered multifactorial, although always involving a traumatic force that raises the liver and drops the hepatoduodenal ligament [
      • Parks R.W.
      • Diamond T.
      Non-surgical trauma to the extrahepatic biliary tract.
      ,
      • Sondenaa K.
      • Horn A.
      • Nedrebo T.
      Diagnosis of blunt trauma to the gallbladder and bile ducts.
      ,
      • Melton S.M.
      • McGwin G.
      • Cross J.M.
      • Davidson J.
      • Waller H.
      • et al.
      Common bile duct transection in blunt abdominal trauma: case report emphasizing mechanism of injury and therapeutic management.
      ]. Other factors implicated include an increasing pressure on the bile duct transmitted to the interior of the main bile duct [
      • Parks R.W.
      • Diamond T.
      Non-surgical trauma to the extrahepatic biliary tract.
      ,
      • Revuelta S.
      • Lopez F.
      • Ortiz R.
      • Fernandez C.
      Lesiones biliares extrahepáticas en el traumatismo abdominal.
      ], the functional status of the sphincter of Oddi, and the type of traumatic agent [
      • Revuelta S.
      • Lopez F.
      • Ortiz R.
      • Fernandez C.
      Lesiones biliares extrahepáticas en el traumatismo abdominal.
      ]. The portal vein and hepatic artery are not usually injured, because they are longer and more elastic than the main bile duct [
      • Parks R.W.
      • Diamond T.
      Non-surgical trauma to the extrahepatic biliary tract.
      ]. If the trauma is major enough to section vascular structures, it is usually mortal [
      • Parks R.W.
      • Diamond T.
      Non-surgical trauma to the extrahepatic biliary tract.
      ]. In this case, the temporary placement of the prosthesis and cholecystectomy probably prolonged local adherences, facilitating the lesion.
      There are 3 injury patterns [
      • Parks R.W.
      • Diamond T.
      Non-surgical trauma to the extrahepatic biliary tract.
      ,
      • Sondenaa K.
      • Horn A.
      • Nedrebo T.
      Diagnosis of blunt trauma to the gallbladder and bile ducts.
      ]: immediate diagnosis in patients undergoing laparotomy for accompanying injuries [
      • Parks R.W.
      • Diamond T.
      Non-surgical trauma to the extrahepatic biliary tract.
      ,
      • Melton S.M.
      • McGwin G.
      • Cross J.M.
      • Davidson J.
      • Waller H.
      • et al.
      Common bile duct transection in blunt abdominal trauma: case report emphasizing mechanism of injury and therapeutic management.
      ], late diagnosis in stable patients with scant symptoms (>50% of cases) [
      • Parks R.W.
      • Diamond T.
      Non-surgical trauma to the extrahepatic biliary tract.
      ], and late complications in patients not diagnosed at the time of the trauma [
      • Parks R.W.
      • Diamond T.
      Non-surgical trauma to the extrahepatic biliary tract.
      ,
      • Melton S.M.
      • McGwin G.
      • Cross J.M.
      • Davidson J.
      • Waller H.
      • et al.
      Common bile duct transection in blunt abdominal trauma: case report emphasizing mechanism of injury and therapeutic management.
      ].
      The diagnosis is usually made in an emergency laparotomy for associated abdominal injuries, when bile is observed in the abdominal cavity or bleeding and/or hematoma in the portal pedicle [
      • Parks R.W.
      • Diamond T.
      Non-surgical trauma to the extrahepatic biliary tract.
      ,
      • Melton S.M.
      • McGwin G.
      • Cross J.M.
      • Davidson J.
      • Waller H.
      • et al.
      Common bile duct transection in blunt abdominal trauma: case report emphasizing mechanism of injury and therapeutic management.
      ]. If an immediate laparotomy is not performed the diagnosis is often considerably delayed [
      • Parks R.W.
      • Diamond T.
      Non-surgical trauma to the extrahepatic biliary tract.
      ,
      • Sondenaa K.
      • Horn A.
      • Nedrebo T.
      Diagnosis of blunt trauma to the gallbladder and bile ducts.
      ,
      • Revuelta S.
      • Lopez F.
      • Ortiz R.
      • Fernandez C.
      Lesiones biliares extrahepáticas en el traumatismo abdominal.
      ]. In fact, there has been an increasing proportion of late diagnoses due to the growing adoption of nonsurgical approaches to the initial treatment of abdominal trauma [
      • Velmahos G.C.
      • Toutouzas K.G.
      • Radin R.
      • Chan L.
      • Demetriades D.
      Non-operative management treatment of blunt injury to solid abdominal organs.
      ]. In these cases, ultrasonography or abdominal computed tomography shows intra-abdominal liquid considered blood and not bile [
      • Revuelta S.
      • Lopez F.
      • Ortiz R.
      • Fernandez C.
      Lesiones biliares extrahepáticas en el traumatismo abdominal.
      ]. A worsening or nonimproving clinical situation, as in our case, can lead to a reassessment of the initial diagnosis. If percutaneous drainage or puncture lavage shows the liquid to have elevated concentrations of amylase and bilirubin, the diagnosis of main bile tract injury is confirmed [
      • Parks R.W.
      • Diamond T.
      Non-surgical trauma to the extrahepatic biliary tract.
      ,
      • Revuelta S.
      • Lopez F.
      • Ortiz R.
      • Fernandez C.
      Lesiones biliares extrahepáticas en el traumatismo abdominal.
      ]. Hydroxy iminodiacetic acid scan, cholangioRM, and endoscopic drainage can be useful in patients who are not immediately diagnosed [
      • Parks R.W.
      • Diamond T.
      Non-surgical trauma to the extrahepatic biliary tract.
      ,
      • Sondenaa K.
      • Horn A.
      • Nedrebo T.
      Diagnosis of blunt trauma to the gallbladder and bile ducts.
      ].
      When the lesion involves at least 50% of the main bile duct circumference, it is treated by choledochorraphy and the insertion of a Kehr tube through a different orifice [
      • Parks R.W.
      • Diamond T.
      Non-surgical trauma to the extrahepatic biliary tract.
      ,
      • Sondenaa K.
      • Horn A.
      • Nedrebo T.
      Diagnosis of blunt trauma to the gallbladder and bile ducts.
      ,
      • Revuelta S.
      • Lopez F.
      • Ortiz R.
      • Fernandez C.
      Lesiones biliares extrahepáticas en el traumatismo abdominal.
      ,
      • Melton S.M.
      • McGwin G.
      • Cross J.M.
      • Davidson J.
      • Waller H.
      • et al.
      Common bile duct transection in blunt abdominal trauma: case report emphasizing mechanism of injury and therapeutic management.
      ,
      • Rodriguez Montes J.A.
      • Rojo E.
      • Martín L.G.
      Complications following repair of extrahepatic bile duct injuries after blunt abdominal trauma.
      ]. This is a rapid and efficacious technique, given that the patients do not normally present with dilation of the duct. Various types of patch have also been used to close the defect with variable outcomes [
      • Parks R.W.
      • Diamond T.
      Non-surgical trauma to the extrahepatic biliary tract.
      ]. Hepaticojejunostomy is the approach of choice if a complete section of the duct is produced [
      • Parks R.W.
      • Diamond T.
      Non-surgical trauma to the extrahepatic biliary tract.
      ,
      • Revuelta S.
      • Lopez F.
      • Ortiz R.
      • Fernandez C.
      Lesiones biliares extrahepáticas en el traumatismo abdominal.
      ,
      • Rodriguez Montes J.A.
      • Rojo E.
      • Martín L.G.
      Complications following repair of extrahepatic bile duct injuries after blunt abdominal trauma.
      ]. A highly selective group of patients, hemodynamically stable and with scant symptoms, can be treated with sphincterotomy, insertion of biliary prosthesis, and percutaneous drainage of the existing bilomas.
      The morbidity associated with main bile duct lesions is approximately 10% [
      • Parks R.W.
      • Diamond T.
      Non-surgical trauma to the extrahepatic biliary tract.
      ], with reports of biliary fistula, hemobilia, biloma, intrahepatic abscesses, stenosis, and cholangitis [
      • Parks R.W.
      • Diamond T.
      Non-surgical trauma to the extrahepatic biliary tract.
      ,
      • Sondenaa K.
      • Horn A.
      • Nedrebo T.
      Diagnosis of blunt trauma to the gallbladder and bile ducts.
      ,
      • Rodriguez Montes J.A.
      • Rojo E.
      • Martín L.G.
      Complications following repair of extrahepatic bile duct injuries after blunt abdominal trauma.
      ]. The mortality in these patients is usually produced by other injuries than the biliary lesion.

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        • Diamond T.
        Non-surgical trauma to the extrahepatic biliary tract.
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        • Nedrebo T.
        Diagnosis of blunt trauma to the gallbladder and bile ducts.
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        Common bile duct transection in blunt abdominal trauma: case report emphasizing mechanism of injury and therapeutic management.
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        Complications following repair of extrahepatic bile duct injuries after blunt abdominal trauma.
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        Non-operative management treatment of blunt injury to solid abdominal organs.
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