What Is Bile?
Bile is a greenish-yellow digestive fluid produced by the liver and stored in the gallbladder (a small organ resembling a sac located in the upper right portion of the abdomen beneath the liver). This fluid consists of bile salts, cholesterol, bilirubin, fats, electrolytes, and water. Its primary function is to carry away waste products and break down fats during digestion. This liquid travels through the liver in a series of tubes called the bile ducts.
What Is Bile Duct Leakage?
The leading cause of bile duct leakage would be the presence of small holes along the ducts, which can cause the bile to leak into the abdominal cavity. The biliary system, which includes the gallbladder and the bile ducts, produces and transports bile into the first part of the small intestine, the duodenum, aiding digestion. Therefore, the leading cause of this condition would be that it can arise due to trauma to the bile ducts or as a complication after surgery like gallbladder removal or liver transplant. This can often result in pain, inflammation, or infection in the abdominal cavity where the bile has leaked.
What Are the Symptoms of Bile Duct Leakage?
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Severe abdominal pain.
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Vomiting.
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Fever.
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Jaundice (skin and the sclera or the whites of the eyes become yellow).
What Is Bile Duct Injury During Surgery?
Bile duct injuries can happen during various procedures. One example would be gallbladder surgery. A common type of gallbladder surgery is laparoscopic cholecystectomy. Surgery performed to remove a diseased gallbladder is called a cholecystectomy. It is done through small cuts through the abdomen. A camera and a light source are attached at the end of the scope and inserted through a small cut made in the stomach. The scope is connected to an external device like a television or a computer through which the doctor can see and perform the surgery. The benefits of this surgery are less hospital time and quick recovery. However, a bile injury such as a cut, burn, or pinch can happen during the procedure. As a result, the duct will not function properly, resulting in leakage and, eventually, bile leaking into the abdomen.
What Causes Bile Duct Injury During Surgery?
Most bile duct injuries during surgeries occur because the area around the gallbladder and bile ducts are not visible during surgery. This can happen if the site where the surgery is performed appears to be different than normal or if there is a lot of bleeding and swelling around the area.
How Is Bile Duct Leakage Diagnosed?
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Intraoperative Cholangiography (IOC): In this test, an X-ray of the bile ducts is taken after injecting a dye to visualize the course of the bile through the X-ray. This test will help the doctors detect the block or a leakage in the bile ducts more clearly.
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Percutaneous Transhepatic Cholangiography: This test is similar to intraoperative cholangiography. In this test, a needle is inserted into the bile duct, followed by an injection of a contrast material to see the bile duct more clearly in the X-ray. This test is more successful than computed tomography or ultrasound. It is performed in individuals in whom performing an endoscopic retrograde cholangiopancreatography (ERCP) was unsuccessful.
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Magnetic Resonance Cholangiopancreatography (MRCP): This test is performed using a combination of radio waves (a powerful magnetic field) and a computer to visualize the internal organs, in this case, the bile ducts.
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Transabdominal Ultrasound: This procedure is used to examine the organs present inside the abdomen. High-energy sound waves create echoes which are then sent to a computer to create images.
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Hepatobiliary Iminodiacetic Acid Scan (HIDA): It is an imaging procedure to diagnose liver, gallbladder, and bile duct problems. Also known as cholescintigraphy or hepatobiliary scintigraphy, it uses a radioactive tracer injected into the vein in the arm.
What Are the Possible Places the Bile Can Leak?
Bile can leak from various anatomical sites, including the cystic duct remnant and the bile duct of Luschka, otherwise known as the subvesical duct (these are small ducts that originate from the right lobe of the liver which usually drains the extrahepatic ducts), or main bile ducts. The most common site for bile duct leakage during surgery would be in the bile duct of Luschka. Therefore, the Strasberg classification for bile injuries from type A to type E is based on the anatomical location within the biliary system.
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Type A - Arises from the cystic duct or an accessory duct.
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Type B - Partial occlusion of the biliary tree, commonly from a deviating right bile duct.
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Type C - Originates from a deviating right hepatic duct but does not communicate with the common bile duct.
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Type D - Lateral injury to a major bile duct without the loss of continuity.
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Type E - It is the most severe type involving complete bile duct transection.
Thus, bile leakage can result from different anatomical sites, and identifying the source of the leaks determines its management.
How Is Bile Duct Leakage Treated?
The standard treatment option for bile duct leakage is endoscopic retrograde cholangiopancreatography and placing a temporary bile duct stent that resembles a plastic straw.
Endoscopic Retrograde Cholangiopancreatography:
This procedure minimally treats problems pertaining to the liver, gallbladder, bile duct, and pancreas. It combines the use of X-rays and upper endoscopy. An endoscope is a long slender tube with a camera and a light source attached to its end. The healthcare professional will guide the endoscope through the mouth and the throat down the esophagus, stomach, and the first part of the small intestine. The healthcare professional can then view the organs inside and check for any problems. Air can be injected into the abdominal cavity to have easy access. Then the professional will pass a thin, slender tube through the endoscope to the biliary tree to inject a contrast dye into the ducts, highlighting the organs in the X-ray. Special tools using the endoscope can be used to place a stent to stop the leakage.
Can Bile Duct Leakage During Surgery Be Prevented?
Some doctors prefer using intraoperative cholangiography more often to help reduce the number and severity of bile duct injuries. In contrast, other doctors believe that not all bile duct leaks can be prevented, even with intraoperative cholangiography. In contrast, some doctors believe that the changes in how the surgery is performed and the equipment used can reduce the severity of some bile duct injuries, which causes leakage.
Conclusion:
Most bile duct injuries have a good prognosis and thus can be repaired. However, some injuries may go unnoticed during surgery. The symptoms can occur weeks after surgery. Therefore, if the patient experiences symptoms of bile duct injury or a leak, the individual should visit the doctor soon. Bile duct injuries remain a potential risk factor while performing surgeries in or near that region since not every bile duct injury can be prevented.
