Bile Duct Injury - Symptoms, Causes, and Treatment

Introduction

A bile duct is a long tube that carries bile. Bile plays an important role in the digestion of food. Bile is produced in the liver and is carried by the hepatic duct and joins the cystic duct, and this forms a common bile duct that ends and opens up in the intestine. The upper half of the bile duct is associated with the liver, while the lower part is the common bile duct linked with the pancreas and ends at the intestine. The biliary tree is the network formed by various sizes of ducts that arise from the liver.

What Is a Bile Duct Injury?

Damage is caused to the bile duct by any kind of trauma or injury during surgery of any adjacent organs, especially during gallbladder surgery. The bile duct can get burned, pinched or cut, or bruised during this type of surgery, resulting in a direct leakage of bile in the abdomen and blocking normal bile flow from the liver. These injuries can lead to pain and death if not treated on time.

How Common Are Bile Duct Injuries During Gallbladder Surgery?

Around ninety percent of bile duct injuries are caused during gallbladder surgery, as the area near the gallbladder and bile duct is masked in some way that the provider is unable to access and see the ducts clearly. And this occurs in the area since it is inaccessible when there is excess bleeding, scarring of the area, and swelling in the gallbladder.

What Are the Symptoms of Bile Duct Injury?

Bile duct injuries are usually detected at the time of surgery. The first sign of a bile duct injury is not able to recover faster after the procedure. The following other symptoms also accompany the condition:

• Abdominal pain.

• Nausea and vomiting.

• Chills.

• Fever.

• Generalized discomfort.

• Jaundice.

• Swelling of the abdomen.

How Is Bile Duct Injury Diagnosed?

Around 30 percent of the cases of bile duct injuries are identified by the health care provider at the time of surgery. Leaking bile and blockage of the bile duct are detected by a test IOC (intraoperative cholangiography). It is a test that is done by taking an X-ray of the bile duct by injecting dyes that makes the duct visibility clear.

Other tests include the following:

• Transabdominal Ultrasound: In this test, sound waves and echoes are used to create and produce images of the organs.

• ERCP (Endoscopic Retrograde Cholangiopancreatography): A flexible lightheaded scope is used to insert into the upper digestive tract, and X-rays are taken. Some bile duct injuries can also be treated using an ERCP.

• MRCP (Magnetic Resonance Cholangiopancreatography): Magnetic resonance imaging is used by using radio waves and large magnets to create images of the body and bile ducts.

• Percutaneous Transhepatic Cholangiography: It is a similar procedure to that of IOC, and during this, a dye is injected into the ducts, and X-rays are taken.

What Is the Treatment Provided for Bile Duct Injury?

Treatment of bile duct injury can range from simple drainage procedures to reconstruction of biliary systems. Strasberg classification can help in guiding the treatment:

Strasberg Type A: Biliary system is continuity with a leak from the cystic duct or hepatic duct through the liver bed.

Treatment of this type is done by the closure of the leak. Endoscopic stenting across the lesion can help to close the leak and facilitate drainage through the biliary system, which decreases pressure in the biliary system. Sphincterotomy can be done in some cases. Some cases can also be treated by coil embolization.

Strasberg Type B: Condition with minimal pain and mild elevation in LFT - liver function test.

Segmental resection is involved as treatment. Percutaneous transhepatic cholangiogram with biliary drainage tube placement or hepaticojejunostomy. Endoscopic management of occlusive injuries is done.

Strasberg Type C: Condition is similar to that of type B.

Same as type B, type C is also managed by endoscopic intervention. Percutaneous drainage of subhepatic biliary leak helps in the closure and prevention of biliary peritonitis.

Strasberg Type D: This type involves partial medial injury to the common bile duct.

A multi-approach is done to ensure proper treatment and avoid further complications. A HIDA (hepatobiliary iminodiacetic acid) scan is done to get two to four weeks after endoscopic stent insertion to evaluate continuous leakage.

Strasberg Type E: This type is treated by T-tube external drainage or a Y-tube that drains in the duodenum. In tension-free conditions, Roux-en-Y hepaticojejunostomy is a preferred reconstructive option.

Repeated evaluation of the injury and leak by ERCP and MRCP for further development of leak and stricture helps in treating the condition successfully.

What Are the Complications of Bile Duct Injury?

Bile duct injuries complication can vary the morbidity potential. The biliary leak can lead to wound infection, intra-abdominal infection, biloma, abscess, and sepsis. The most serious complication of bile duct injury is stricture which can be conservatively treated. Complications also include pulmonary embolism, bleeding, uncontrolled sepsis, and anastomosis.

What Is the Differential Diagnosis With Bile Duct Injury?

Individuals with continued symptoms of nausea, vomiting, and jaundice after gallbladder surgery can have differential diagnoses other than bile duct injury:

• Biliary dyskinesia.

• Sphincter of Oddi dysfunction.

• Stricture.

• Retained gallstones.

Individuals can also exhibit the following symptoms like extra biliary disorders:

• Pancreatitis.

• Pancreatic masses, mesenteric ischemia.

• Diverticulitis.

• Intestinal motility disorders.

• Pancreas divisum.

• Peptic ulcer disease.

Rarely do individuals exhibit extra-intestinal disorders such as:

• Psychiatric disorders.

• Coronary artery disease.

How Is the Prognosis Of Bile Duct Injury?

Bile duct injury can lead to very serious complications if not properly managed. Conditions like cirrhosis, portal hypertension, strictures, and ascending cholangitis can occur. Long-term survival and quality of life are compromised with high rates of litigation. Factors that are associated with successful repair are intraoperative cholangiography and intra-abdominal infection. Controlling intra-abdominal sepsis can influence the success of the repair.

Conclusion:

Bile duct injury is a serious and challenging condition for a health provider. In complicated cases, hepatobiliary transplant surgeons may also intervene in the treatment. Bile duct injury is a rare surgical complication. Bailout procedures or aborting the procedures can prevent further damage in case of injury, severe scarring, and inflammation.