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Complete avulsion of the common bile duct as a result of blunt abdominal trauma—Case report of a child
Complete Avulsion of the Common Bile Duct as a Result of Blunt Abdominal Traumarase
Report of a Child
By ADOLFO MARTINEZ CARO AND Jo& M. OCANA LOSA
RAUMA to the biliary tree in children, excluding iatrogenic lesions, is usually the result of closed abdominal trauma.l Usually these injuries are serious enough for the patient to be taken to the hospital, but as the clinical picture is frequently vague, the possibility of biliary injury must be kept in mind as delayed treatment of these injuries is more often the rule than the exception. We have seen a complete division of the common bile duct, as an isolated injury resulting from blunt abdominal trauma, in a three-year-old child. A choledochoduodenostomy was performed, resulting in full recovery.
T
CASE REPORT A three-year-old boy, was admitted to the Hospital General de Asturias five hours after a heavy metal bar from a plow had fallen on his abdomen. Soon after, he had epigastric pain, vomiting, pallor and cold sweats. The pain later moved to the RLQ. When seen in the emergency clinic he was pale and with a heart rate of 170 to 180 per minute, but after he vomited several times his pulse dropped to 124/min. His B.P. was 110/60 and temperature 36.8”C. The abdomen was generally tender with guarding in the RLQ and absence of bowel sounds. The chest X-ray was normal; the abdominal film showed no sign of ruptured viscera, but a shadow of appendicolith was suggested. WBC was 24,200 with more than 88 per cent neutrophiles. The hemoglobin was 13 gms%, and the hematocrit 39 per cent. The general condition of the patient stabilized, and 12 hours following admission his abdomen had not changed, but his pulse rate had increased to 160/min., and the temperature had risen to 37.6”C. We decided, then, to proceed with laparotomy. At operation there was free blood and bile in the abdomen. The distal end of the common bile duct was torn and leaking bile (Fig. 1A). This, and a hematoma in the head of the pancreas, were the only lesions found. A choledochoduodenostomy was performed through an anterior duodenostomy and over polyethylene tubing no. 18 (Fig. 1B). The choledocal mucosa was sutured to the duodenal mucosa with interrupted silk. The splinting tube was brought out through the duodenum and a stab wound. An anchoring suture was used to hold the duct to the duodenum externally. The child had a satisfactory postoperative course and on the 20th day a tube cholangiogram showed a normal biliary tree with good drainage into the duodenum (Fig. 1C). The polyethylene tube was removed soon after. Three months after the accident, an intravenous cholangiogram showed no stenosis of the common bile duct nor retention of the contrast material. The serum bilirubin was normal. DISCUSSION Rupture of the biliary tree was first described by Battle2 in 1893. There only 13 reports of complete division of the common bile duct in children.3*4
From
the Service
of Pediatric
Surgery,
Hospital
General
de Asturias,
Oviedo,
are
Spain.
A~OLFO MARTINEZ CARO, M.D.: Surgeon-in-charge, Service of Pediatric Surgery, Hospital General de Asturias, Oviedo, Spain. Jo& M. OCANA LOSA, M.D.: Assistant Surgeon, Service of Pediatric
60
Surgery,
Hospital
General
de Asturias,
Oviedo,
Spain.
JOURNAL OF PEDIATRICSURGERY,VOL. 5, No.
1 (FEBRUARY), 1970
COMPLETE
A
AVULSJON
OF THE COMMON
BILE DUCT
61
B
Fig. l.-(a). Line drawing of avulsed common bile duct as found at operation. (b). Diagram of choledochoduodenostomy. (c). Tube-cholangiogram at 20th day postop. Contrast medium in the duodenum.
62
CAR0
AND
LOSA
Some authors believe that isolated injuries to the common bile duct are rare and usually accompanied by injury to other organs.;‘,” Hepp,’ on the other hand, feels that traumatic lesions to the bile duct are almost always isolated lesions, and not the result of grave abdominal trauma, but the consequence of specific injury to the upper abdomen. The biliary peritonitis that all these patients present seems to be of a benign nature, but does produce clinical signs and symptoms. The picture of slow loss of bile, jaundice, acholic feces and anorexia is well documented. Frequently, children are observed in the hospital for several days and then discharged apparently well, only to be readmitted shortly after with the same picture described above. If the common duct or the hepatic duct is the only structure injured, the syndrome of biliary peritonitis appears within three days.” According to the literature consulted, the majority of patients are not explored surgically until 24 hours to 30 days have elapsed, the average being three to seven days. Blunt abdominal trauma, with injury to the liver and bile ducts, is accompanied by a high mortality rate, particularly in children. Very frequently these patients with blood and/or bile in the abdomen present an important tachycardiaX and a high WBC.” The surgical technique used in the treatment of these patients has to b:: improvised in the operating room, depending on the type of lesion found. The objective is to reestablish the integrity of the biliary tree by the most suitable type of anastomosis. SUMMARY Blunt abdominal trauma in a three-year-old child produced a completn rupture of the common bile duct from the duodenum. After a delay of only 12 hours, a choledochoduodenostomy was performed with recovery. This seems to be the 14th sure lesion reported in the pediatric age group. REFERENCES
1. Hartman, S. W., and Greaney, E. M., Jr.: Traumatic injuries to the biliary system in children. Amer. J. Surg. 108:150, 1964. 2. Battle, W. H.: Traumatic rupture of the common bile duct. Trans. Clin. Sot. 27: 144, 1894. 3. Ladd, W. E., and Gross, R. E.: Abdominal Surgery of Infancy and Childhood. Philadelphia, Saunders, 1941, p. 295. 4. Noone, R. B., Mackie, J. A., and Stoner, R.: Liver and bile duct laceration from blunt abdominal trauma in children. Ann. Surg. 166:824, 1967. 5. Dorton, H. E.: Complete division of the common bile duct due to blunt abdominal trauma. Case report. Amer. Surg. 31:
333, 1965. 6. Manlove, C. H., Quattlebaum, F. W., and Ambrus, L.: Non-penetrating trauma to the biliary tract. Amer. J. Surg. 97: 113. 1959. 7. Hepp, J.. Moreaux, J., and Bismuth, H.: Les ruptures de la Voie biliare principale au cows des traumatismes fermes de I’abdomen. Ann. Chir. 18:953, 1964. 8. Glenn, F.: Injuries to the liver and biliary tract. Amer. J. Surg. 91:534, 1956. 9. Berman, J. K., Habegger, E. D., Fields. D. C., and Kilmer, W. L.: Blood studies as an aid in differential diagnosis of abdominal trauma. JAMA 165:1537, 1957.
Report of a Child
By ADOLFO MARTINEZ CARO AND Jo& M. OCANA LOSA
RAUMA to the biliary tree in children, excluding iatrogenic lesions, is usually the result of closed abdominal trauma.l Usually these injuries are serious enough for the patient to be taken to the hospital, but as the clinical picture is frequently vague, the possibility of biliary injury must be kept in mind as delayed treatment of these injuries is more often the rule than the exception. We have seen a complete division of the common bile duct, as an isolated injury resulting from blunt abdominal trauma, in a three-year-old child. A choledochoduodenostomy was performed, resulting in full recovery.
T
CASE REPORT A three-year-old boy, was admitted to the Hospital General de Asturias five hours after a heavy metal bar from a plow had fallen on his abdomen. Soon after, he had epigastric pain, vomiting, pallor and cold sweats. The pain later moved to the RLQ. When seen in the emergency clinic he was pale and with a heart rate of 170 to 180 per minute, but after he vomited several times his pulse dropped to 124/min. His B.P. was 110/60 and temperature 36.8”C. The abdomen was generally tender with guarding in the RLQ and absence of bowel sounds. The chest X-ray was normal; the abdominal film showed no sign of ruptured viscera, but a shadow of appendicolith was suggested. WBC was 24,200 with more than 88 per cent neutrophiles. The hemoglobin was 13 gms%, and the hematocrit 39 per cent. The general condition of the patient stabilized, and 12 hours following admission his abdomen had not changed, but his pulse rate had increased to 160/min., and the temperature had risen to 37.6”C. We decided, then, to proceed with laparotomy. At operation there was free blood and bile in the abdomen. The distal end of the common bile duct was torn and leaking bile (Fig. 1A). This, and a hematoma in the head of the pancreas, were the only lesions found. A choledochoduodenostomy was performed through an anterior duodenostomy and over polyethylene tubing no. 18 (Fig. 1B). The choledocal mucosa was sutured to the duodenal mucosa with interrupted silk. The splinting tube was brought out through the duodenum and a stab wound. An anchoring suture was used to hold the duct to the duodenum externally. The child had a satisfactory postoperative course and on the 20th day a tube cholangiogram showed a normal biliary tree with good drainage into the duodenum (Fig. 1C). The polyethylene tube was removed soon after. Three months after the accident, an intravenous cholangiogram showed no stenosis of the common bile duct nor retention of the contrast material. The serum bilirubin was normal. DISCUSSION Rupture of the biliary tree was first described by Battle2 in 1893. There only 13 reports of complete division of the common bile duct in children.3*4
From
the Service
of Pediatric
Surgery,
Hospital
General
de Asturias,
Oviedo,
are
Spain.
A~OLFO MARTINEZ CARO, M.D.: Surgeon-in-charge, Service of Pediatric Surgery, Hospital General de Asturias, Oviedo, Spain. Jo& M. OCANA LOSA, M.D.: Assistant Surgeon, Service of Pediatric
60
Surgery,
Hospital
General
de Asturias,
Oviedo,
Spain.
JOURNAL OF PEDIATRICSURGERY,VOL. 5, No.
1 (FEBRUARY), 1970
COMPLETE
A
AVULSJON
OF THE COMMON
BILE DUCT
61
B
Fig. l.-(a). Line drawing of avulsed common bile duct as found at operation. (b). Diagram of choledochoduodenostomy. (c). Tube-cholangiogram at 20th day postop. Contrast medium in the duodenum.
62
CAR0
AND
LOSA
Some authors believe that isolated injuries to the common bile duct are rare and usually accompanied by injury to other organs.;‘,” Hepp,’ on the other hand, feels that traumatic lesions to the bile duct are almost always isolated lesions, and not the result of grave abdominal trauma, but the consequence of specific injury to the upper abdomen. The biliary peritonitis that all these patients present seems to be of a benign nature, but does produce clinical signs and symptoms. The picture of slow loss of bile, jaundice, acholic feces and anorexia is well documented. Frequently, children are observed in the hospital for several days and then discharged apparently well, only to be readmitted shortly after with the same picture described above. If the common duct or the hepatic duct is the only structure injured, the syndrome of biliary peritonitis appears within three days.” According to the literature consulted, the majority of patients are not explored surgically until 24 hours to 30 days have elapsed, the average being three to seven days. Blunt abdominal trauma, with injury to the liver and bile ducts, is accompanied by a high mortality rate, particularly in children. Very frequently these patients with blood and/or bile in the abdomen present an important tachycardiaX and a high WBC.” The surgical technique used in the treatment of these patients has to b:: improvised in the operating room, depending on the type of lesion found. The objective is to reestablish the integrity of the biliary tree by the most suitable type of anastomosis. SUMMARY Blunt abdominal trauma in a three-year-old child produced a completn rupture of the common bile duct from the duodenum. After a delay of only 12 hours, a choledochoduodenostomy was performed with recovery. This seems to be the 14th sure lesion reported in the pediatric age group. REFERENCES
1. Hartman, S. W., and Greaney, E. M., Jr.: Traumatic injuries to the biliary system in children. Amer. J. Surg. 108:150, 1964. 2. Battle, W. H.: Traumatic rupture of the common bile duct. Trans. Clin. Sot. 27: 144, 1894. 3. Ladd, W. E., and Gross, R. E.: Abdominal Surgery of Infancy and Childhood. Philadelphia, Saunders, 1941, p. 295. 4. Noone, R. B., Mackie, J. A., and Stoner, R.: Liver and bile duct laceration from blunt abdominal trauma in children. Ann. Surg. 166:824, 1967. 5. Dorton, H. E.: Complete division of the common bile duct due to blunt abdominal trauma. Case report. Amer. Surg. 31:
333, 1965. 6. Manlove, C. H., Quattlebaum, F. W., and Ambrus, L.: Non-penetrating trauma to the biliary tract. Amer. J. Surg. 97: 113. 1959. 7. Hepp, J.. Moreaux, J., and Bismuth, H.: Les ruptures de la Voie biliare principale au cows des traumatismes fermes de I’abdomen. Ann. Chir. 18:953, 1964. 8. Glenn, F.: Injuries to the liver and biliary tract. Amer. J. Surg. 91:534, 1956. 9. Berman, J. K., Habegger, E. D., Fields. D. C., and Kilmer, W. L.: Blood studies as an aid in differential diagnosis of abdominal trauma. JAMA 165:1537, 1957.