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An unusual bile duct injury in a child after blunt abdominal trauma
An Unusual Bile Duct Injury in a Child After Blunt Abdominal Trauma By
Soliman
Bin Yahib,
Abdullah
Riyadh,
Al Rabeeah,
and
Asal
Al Sammarrai
Saudi Arabia
Bile duct injuries are rare in children after blunt trauma. This report describes a 3-year-old child who sustained a blunt abdominal trauma resulting in bile duct, liver, and small bowel injuries. The initial management at another hospital included recognition and repair of a small bowel perforation. However, the postoperative course was complicated by a large biliary leak. The child was transferred to our institution where radioisotope scanning and endoscopic retrograde cholangiography confirmed the extent of the ductal injury. At laparotomy there were injuries of both right and left hepatic
ducts, and an anomaly of bile duct course was noted. The right hepatic duct was repaired primarily and the left one was repaired with Roux-en-Y hepaticojejunostomy. Postoperatively, normal bile drainage was documented by radioisotope scan and the patient remains symptom free at 1 year followup. J Pediatr Sorg 34:1161-l 163. Copyright o 1999 by W.B. Saunders Company.
E
cystic duct at the retroduodenal part of the CBD. There were tears of both hepatic ducts involving half the circumference of the left duct and a small tear of the right duct (Fig 2). The right duct was repaired prrmarily, the left duct was repaired using a Roux-en-Y hepaticojejunostomy. and an incidental cholecystectomy was performed. Postoperatively, the patient had a satrsfactory recovery and was started on oral intake on the sixth postoperative day. He was discharged 3 weeks from the time of admission. A postoperative HIDA scan 1 month after discharge showed good flow into the gastrointestinal tract (Fig 3). At 1 year of follow-up the child remains symptom free.
XTRAI-IEPATIC BILE DUCT injury is rare and often diagnosed late. 1-3The majority of bile duct injuries in children are caused by blunt abdominal trauma.2 We report a case of traumatic injury to both hepatic ducts in a 3-year-old boy. The diagnostic and therapeutic approach to this rare and difficult injury is reviewed.
CASE
WORDS:
Blunt
abdominal
injury,
bile
duct,
bile
leak.
REPORT
A 3-year-old boy was admitted to another hospital after he was run over by an ice cream van. A small bowel injury was diagnosed, and he underwent laparotomy. A small bowel tear was repaired primarily, the abdomen was irrigated, and a drain was placed in the right lower quadrant. No bile leak was noted and no other intraabdominal injuries were observed. Two days later a bile leak was observed through the drain. Computed tomography (CT) scan was done and showed a suprahepatic collection and laceration of the liver. On the 1 lth day postmjury, the child was referred to our hospital. At presentation the child appeared ill. but not jaundiced, and had a temperature of 38.6”C. Abdominal examination showed significant distention and a large amount of bile drainage from the right lower quadrant drain site. His mitial blood work showed white blood cell count of 24,0, and his liver functron test results were normal. The child was started on parenteral nutritron and broad-spectrum antibiotic therapy. As the child’s condition improved, a HIDA scan was performed, which showed no flow of isotope into the gastrointestinal tract and an accumulation of isotope in the subhepatic area (Fig 1). An endoscopic retrograde cholangiopancreatography (ERCP) was performed and showed a definite bile duct leak in the supraduodenal area. The ERCP was complicated by transient pancreatitis. When the pancreatitis improved, a laparotomy was performed and surgical cholangiography visualized the distal part of the common bile duct (CBD) with no leak and good flow of contrast to the duodenum. However, the proximal part of the biliary system could not be visualized. Exploratron of the CBD showed an anomaly of the extrahepatic ductal system consisting of unusually long hepatic ducts joining at the supraduodenal area and low insertion of the JournalofPediatricSurgery,
INDEX
Vol 34, No 7 (July),
1999, pp 1161-1163
DISCUSSION
Extrahepatic bile duct injuries are rare after blunt abdominal trauma, with approximately 125 cases being reported in the literature between 1806 and 1994.‘** Nearly one third of these injuries occurred in children.2 The most commonly injured areas of the biliary tract, in descending order of frequency, are the gallbladder, CBD, confluence of hepatic ducts, and finally the left hepatic duct.3,4 Isolated hepatic duct injury also is rare with approximately 33 cases reported in the literature up to 1996 with less than half of these occurring in children.3-8 Our case of injury to both right and left hepatic ducts, we believe, is only the second case to be reported in the pediatric
From the Department of Surgery King Fahad Nattonal Guard Hospital, Riyadh, Saudi Arabia. Presented at the 30th Annual Meeting of the Canadran Associatron of Paediatti Surgeons, Toronto. Ontario, Canada, September 25-28. 1998. Address reprint requests to Dr A. Al Rabeeah. King Fahad National Guard Hospital, PO Box 22490, Rtyadh 11426, Saudi Arabia. Copyright 6 1999 by WB. Saunders Company 0022-3468/99/3407-0028$03.00/O 1161
1162
YAHIB,
AL RABEEAH,
AND
AL SAMMARRAI
1
5
G
7
8
“St
Fig 1. of isotope
Preoperative HIDA scan shows into the gastrointestinal tract.
diffuse
bile leak and no flow
popu1ation.Q The most common causes of these injuries is penetrating trauma, especially among teenagers and adults.3 However, blunt trauma is the main cause of biliary tract injuries in children, with the mechanisms of injury including motor vehicle accidents, assault, kick by a horse, or bicycle accidents.3,4s9The mortality rate in patients with blunt injuries to the extra hepatic ducts is significantly higher (50%) than in those with penetrating injuries to the biliary system (8.3%).3 The postulated pathophysiology of the blunt injury includes increased intraductal pressure, shearing forces at site of fixation of the ducts, compression against the vertebrae, and ischemic necrosis to ducts.lOJ1 The fact that our patient had a delayed bile leak, secondary to injury of both the right and left hepatic ducts, suggests an ischemic necrosis
Fig 2.
Diagrammatic
representation
of the hepatic
duct
injury.
Fig 3. HIDA scan 1 month isotope into the gastrointestinal
postoperatively tract.
shows
normal
flow
of
of the ducts. In addition, the long anomalous course of the hepatic ducts may have predisposed them to injury. Diagnosis of isolated bile duct injuries is difficult and often is delayed, with an average time of 18 days.2 Bile is sterile and can produce minimal peritoneal irritation, so the course of presentation can be chronic and consists of mild peritoneal signs, jaundice, low-grade fever, and weight loss. A high index of suspicion guided by the history of the mechanism of injury, serial clinical assessment, and timely utilization of diagnostic modalities, including peritoneal tap, ultrasonography, CT scan, ERCP, and HIDA scan, is therefore essential2 A variety of treatment options have been used for biliary tract injuries with the choice of treatment being dictated by type and degree of injury and the general condition of the patient. Small tears have been treated using any of the following options: ERCP and stenting,5 primary repair,3+9and patch repair with vein, serosa or jejunal patch.4*9 In addition, t-tube decompression3 and enterohepatoduodenal ligamentostomyt have been used in difficult cases. Choledochoenterostomy and hepaticoenterostomy have been used for major injuries of the ducts, including complete transection.2*3q9In our case, we used both primary repair for the right hepatic duct and hepaticojejunostomy for the left duct. Extrahepatic bile duct injury is uncommon, and hepatic duct injury is very rare. However, anomalies of the biliary tract may predispose to their injury. A high index of suspicion using the history of the mechanism of injury, serial physical examinations supported by radiological and endoscopic studies may help in early diagnosis.
UNUSUAL
BILE DUCT
INJURY
1163
REFERENCES I. Bar-Maor JA. Shoshany G: Traumatic rupture of the choledochus treated temporarily by roux-en-y entero-hepato-duodenal ligamentostomy. J Pediatr Surg 29:1578-1579, 1994 2. Bourque MD, Spigland N, Bensoussan AL, et al: Isolated complete transection of common bile duct due to trauma in a child, and revtew of the hterature. J Pediatr Surg 24: 1068- 1070, 1989 3. Ivatury RR, Rohman M, Hellathambi M, et al: The morbidity of injurtes of the extra-hepatic system. J Trauma 25:967-973, 1985 4. Monk JS, Church JS, Agarawal N: Repair of a traumatic noncircumferential hepatic bile duct using a vein patch: Case report. J Trauma31:1555-1557. 1991 5. Eid A, Almogy G, Pikasky AJ, et al: Conservative treatment of a traumatic tear of the left hepatic duct: Case Report. J Trauma 41:912-913, 1996 6. Michelasst F. Ranson JH: Bile duct disruption by blunt trauma. J Trauma 25:454-457, 1985
7. Kemohan RM, Humphreys WG: Closed abdominal child causing avulsion of the common bile duct and gastric 16:235-237, 1985 8. Krishna inJury:
duct
7: 143-145.
A, Kaul PB, Murali MV, et al. Isolated Diagnosis and surgical management.
trauma in a stasis. Injury
extrahepatic bile Pedtatr Sur Int
1992
9. Bade PG. Thomson SR, Hirshberg A. et al: Surgical options m traumatic injury to the extrahepatic biliary tract. Br J Surg 76256-258, 1989
10. Jones KB, Thomas E: Traumatic rupture of hepatic duct demonstrated by endoscopic retrograde cholangiography. J Trauma 25:448449, 1985
11. Gately JF, Thomas EJ: Post traumatic ischemic common bde duct. Can J Surg 28:32-33, 1985
necrosis
of the
Soliman
Bin Yahib,
Abdullah
Riyadh,
Al Rabeeah,
and
Asal
Al Sammarrai
Saudi Arabia
Bile duct injuries are rare in children after blunt trauma. This report describes a 3-year-old child who sustained a blunt abdominal trauma resulting in bile duct, liver, and small bowel injuries. The initial management at another hospital included recognition and repair of a small bowel perforation. However, the postoperative course was complicated by a large biliary leak. The child was transferred to our institution where radioisotope scanning and endoscopic retrograde cholangiography confirmed the extent of the ductal injury. At laparotomy there were injuries of both right and left hepatic
ducts, and an anomaly of bile duct course was noted. The right hepatic duct was repaired primarily and the left one was repaired with Roux-en-Y hepaticojejunostomy. Postoperatively, normal bile drainage was documented by radioisotope scan and the patient remains symptom free at 1 year followup. J Pediatr Sorg 34:1161-l 163. Copyright o 1999 by W.B. Saunders Company.
E
cystic duct at the retroduodenal part of the CBD. There were tears of both hepatic ducts involving half the circumference of the left duct and a small tear of the right duct (Fig 2). The right duct was repaired prrmarily, the left duct was repaired using a Roux-en-Y hepaticojejunostomy. and an incidental cholecystectomy was performed. Postoperatively, the patient had a satrsfactory recovery and was started on oral intake on the sixth postoperative day. He was discharged 3 weeks from the time of admission. A postoperative HIDA scan 1 month after discharge showed good flow into the gastrointestinal tract (Fig 3). At 1 year of follow-up the child remains symptom free.
XTRAI-IEPATIC BILE DUCT injury is rare and often diagnosed late. 1-3The majority of bile duct injuries in children are caused by blunt abdominal trauma.2 We report a case of traumatic injury to both hepatic ducts in a 3-year-old boy. The diagnostic and therapeutic approach to this rare and difficult injury is reviewed.
CASE
WORDS:
Blunt
abdominal
injury,
bile
duct,
bile
leak.
REPORT
A 3-year-old boy was admitted to another hospital after he was run over by an ice cream van. A small bowel injury was diagnosed, and he underwent laparotomy. A small bowel tear was repaired primarily, the abdomen was irrigated, and a drain was placed in the right lower quadrant. No bile leak was noted and no other intraabdominal injuries were observed. Two days later a bile leak was observed through the drain. Computed tomography (CT) scan was done and showed a suprahepatic collection and laceration of the liver. On the 1 lth day postmjury, the child was referred to our hospital. At presentation the child appeared ill. but not jaundiced, and had a temperature of 38.6”C. Abdominal examination showed significant distention and a large amount of bile drainage from the right lower quadrant drain site. His mitial blood work showed white blood cell count of 24,0, and his liver functron test results were normal. The child was started on parenteral nutritron and broad-spectrum antibiotic therapy. As the child’s condition improved, a HIDA scan was performed, which showed no flow of isotope into the gastrointestinal tract and an accumulation of isotope in the subhepatic area (Fig 1). An endoscopic retrograde cholangiopancreatography (ERCP) was performed and showed a definite bile duct leak in the supraduodenal area. The ERCP was complicated by transient pancreatitis. When the pancreatitis improved, a laparotomy was performed and surgical cholangiography visualized the distal part of the common bile duct (CBD) with no leak and good flow of contrast to the duodenum. However, the proximal part of the biliary system could not be visualized. Exploratron of the CBD showed an anomaly of the extrahepatic ductal system consisting of unusually long hepatic ducts joining at the supraduodenal area and low insertion of the JournalofPediatricSurgery,
INDEX
Vol 34, No 7 (July),
1999, pp 1161-1163
DISCUSSION
Extrahepatic bile duct injuries are rare after blunt abdominal trauma, with approximately 125 cases being reported in the literature between 1806 and 1994.‘** Nearly one third of these injuries occurred in children.2 The most commonly injured areas of the biliary tract, in descending order of frequency, are the gallbladder, CBD, confluence of hepatic ducts, and finally the left hepatic duct.3,4 Isolated hepatic duct injury also is rare with approximately 33 cases reported in the literature up to 1996 with less than half of these occurring in children.3-8 Our case of injury to both right and left hepatic ducts, we believe, is only the second case to be reported in the pediatric
From the Department of Surgery King Fahad Nattonal Guard Hospital, Riyadh, Saudi Arabia. Presented at the 30th Annual Meeting of the Canadran Associatron of Paediatti Surgeons, Toronto. Ontario, Canada, September 25-28. 1998. Address reprint requests to Dr A. Al Rabeeah. King Fahad National Guard Hospital, PO Box 22490, Rtyadh 11426, Saudi Arabia. Copyright 6 1999 by WB. Saunders Company 0022-3468/99/3407-0028$03.00/O 1161
1162
YAHIB,
AL RABEEAH,
AND
AL SAMMARRAI
1
5
G
7
8
“St
Fig 1. of isotope
Preoperative HIDA scan shows into the gastrointestinal tract.
diffuse
bile leak and no flow
popu1ation.Q The most common causes of these injuries is penetrating trauma, especially among teenagers and adults.3 However, blunt trauma is the main cause of biliary tract injuries in children, with the mechanisms of injury including motor vehicle accidents, assault, kick by a horse, or bicycle accidents.3,4s9The mortality rate in patients with blunt injuries to the extra hepatic ducts is significantly higher (50%) than in those with penetrating injuries to the biliary system (8.3%).3 The postulated pathophysiology of the blunt injury includes increased intraductal pressure, shearing forces at site of fixation of the ducts, compression against the vertebrae, and ischemic necrosis to ducts.lOJ1 The fact that our patient had a delayed bile leak, secondary to injury of both the right and left hepatic ducts, suggests an ischemic necrosis
Fig 2.
Diagrammatic
representation
of the hepatic
duct
injury.
Fig 3. HIDA scan 1 month isotope into the gastrointestinal
postoperatively tract.
shows
normal
flow
of
of the ducts. In addition, the long anomalous course of the hepatic ducts may have predisposed them to injury. Diagnosis of isolated bile duct injuries is difficult and often is delayed, with an average time of 18 days.2 Bile is sterile and can produce minimal peritoneal irritation, so the course of presentation can be chronic and consists of mild peritoneal signs, jaundice, low-grade fever, and weight loss. A high index of suspicion guided by the history of the mechanism of injury, serial clinical assessment, and timely utilization of diagnostic modalities, including peritoneal tap, ultrasonography, CT scan, ERCP, and HIDA scan, is therefore essential2 A variety of treatment options have been used for biliary tract injuries with the choice of treatment being dictated by type and degree of injury and the general condition of the patient. Small tears have been treated using any of the following options: ERCP and stenting,5 primary repair,3+9and patch repair with vein, serosa or jejunal patch.4*9 In addition, t-tube decompression3 and enterohepatoduodenal ligamentostomyt have been used in difficult cases. Choledochoenterostomy and hepaticoenterostomy have been used for major injuries of the ducts, including complete transection.2*3q9In our case, we used both primary repair for the right hepatic duct and hepaticojejunostomy for the left duct. Extrahepatic bile duct injury is uncommon, and hepatic duct injury is very rare. However, anomalies of the biliary tract may predispose to their injury. A high index of suspicion using the history of the mechanism of injury, serial physical examinations supported by radiological and endoscopic studies may help in early diagnosis.
UNUSUAL
BILE DUCT
INJURY
1163
REFERENCES I. Bar-Maor JA. Shoshany G: Traumatic rupture of the choledochus treated temporarily by roux-en-y entero-hepato-duodenal ligamentostomy. J Pediatr Surg 29:1578-1579, 1994 2. Bourque MD, Spigland N, Bensoussan AL, et al: Isolated complete transection of common bile duct due to trauma in a child, and revtew of the hterature. J Pediatr Surg 24: 1068- 1070, 1989 3. Ivatury RR, Rohman M, Hellathambi M, et al: The morbidity of injurtes of the extra-hepatic system. J Trauma 25:967-973, 1985 4. Monk JS, Church JS, Agarawal N: Repair of a traumatic noncircumferential hepatic bile duct using a vein patch: Case report. J Trauma31:1555-1557. 1991 5. Eid A, Almogy G, Pikasky AJ, et al: Conservative treatment of a traumatic tear of the left hepatic duct: Case Report. J Trauma 41:912-913, 1996 6. Michelasst F. Ranson JH: Bile duct disruption by blunt trauma. J Trauma 25:454-457, 1985
7. Kemohan RM, Humphreys WG: Closed abdominal child causing avulsion of the common bile duct and gastric 16:235-237, 1985 8. Krishna inJury:
duct
7: 143-145.
A, Kaul PB, Murali MV, et al. Isolated Diagnosis and surgical management.
trauma in a stasis. Injury
extrahepatic bile Pedtatr Sur Int
1992
9. Bade PG. Thomson SR, Hirshberg A. et al: Surgical options m traumatic injury to the extrahepatic biliary tract. Br J Surg 76256-258, 1989
10. Jones KB, Thomas E: Traumatic rupture of hepatic duct demonstrated by endoscopic retrograde cholangiography. J Trauma 25:448449, 1985
11. Gately JF, Thomas EJ: Post traumatic ischemic common bde duct. Can J Surg 28:32-33, 1985
necrosis
of the