Central Journal of Liver and Clinical Research

Cite this article: Cappiello CD, Darwin PE, Alaish SM (2015) A Chronic Biliary Stricture Following Blunt Abdominal Trauma. J Liver Clin Res 2(3): 1016.

*Corresponding authorSamuel M. Alaish, Associate Professor of Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Bloomberg Children’s Center, Suite 7331, 1800 Orleans Street, Baltimore, MD 21287-0005, USA, Tel: 443-287-3160; Fax: 410-502-5314; Email:

Submitted: 07 May 2015

Accepted: 29 June 2015

Published: 01 July 2015

ISSN: 2379-0830

Copyright© 2015 Alaish et al.

OPEN ACCESS

Keywords•Biliary stricture•Trauma•Pediatric•ERCP•Hepaticojejunostomy

Case Report

A Chronic Biliary Stricture Following Blunt Abdominal TraumaClint D. Cappiello1, Peter E. Darwin2 and Samuel M. Alaish3*1Department of Surgery, University of Maryland School of Medicine, USA2Department of Medicine, University of Maryland School of Medicine, USA3Department of Surgery, Johns Hopkins University School of Medicine, USA

Abstract

Biliary injuries following blunt abdominal trauma are rare in both children and adults. Typically, they present in a delayed fashion one to four weeks following the trauma. Endoscopic and/or radiologic procedures are often sufficient to resolve the injury without the need for surgery. We report a 13 year old boy who presented with an unusual case of a long, chronic biliary stricture diagnosed seven months following an all-terrain vehicle (ATV) accident. Endoscopic retrograde cholangiopancreatography (ERCP) and stent placement temporized the patient, and surgery with a hepatico- jejunostomy provided the definitive treatment.

ABBREVIATIONSATV: All-Terrain Vehicle; ERCP: Endoscopic Retrograde

Cholangiopancreatography; Cm: Centimeter

INTRODUCTIONBiliary injuries following blunt abdominal trauma are rare in

adults [1] and reported even less often in the pediatric population [2]. Biliary injuries encompass all injuries to the gall bladder, the intrahepatic and the extra hepatic bile ducts. These injuries may range from a major ductal injury, which is usually diagnosed early, to a minor injury, which typically presents in a delayed fashion approximately 1 to 4 weeks later [2-4]. The delayed presentation may be one of a postoperative biliary fistula, bile peritonitis, a biloma, or a biliary stricture. In this case report, we present a biliary stricture which became symptomatic five to seven months following an ATV accident involving a 13 year old boy. Based upon our review of the literature, this is the longest interval over reported between the inciting trauma and eventual symptoms. Moreover, the 3 cm stricture was quite longer than those reported in earlier series [3,4].

CASE PRESENTATIONA previously healthy, thirteen-year-old boy was involved

in a severe ATV accident, in which he sustained multiple long bone, vertebral, facial and pelvic fractures, pulmonary contusions, and an intracranial hemorrhage. His abdominal CT scan at that time was negative with respect to any other injury. He recovered fully over the next few months, and then, seven months following the accident, he presented to an outside

facility with a two-day history of abdominal pain, nausea, non-bilious, non-bloody emesis, diarrhea and jaundice. Upon further questioning, the patient described abdominal pain exacerbated by eating, which had progressively worsened over the preceding two months and culminated in an inability to tolerate anything by mouth.Ultrasonography revealed a dilated common bile duct at 1.7 cm with intrahepatic biliary ductal dilation and sludge in the gallbladder without evidence of cholelithiasis or choledocholithiasis. Laboratory studies revealed elevated liver function tests and a serum lipase, as noted in Table 1.

Following transfer to our institution, physical examination demonstrated a well appearing, adolescent male with mild jaundice and right upper quadrant and epigastric tenderness without peritonitis. He was afebrile with stable vital signs. The patient was admitted to the pediatric surgery service, made NPO and placed on intravenous hydration, as well as empiric antibiotics. The adult gastroenterology service was consulted to perform an ERCP. On the day of admission, he was taken to the endoscopy suite where a 3cm, tapering, distal common bile duct stricture was encountered. Sphincterotomy and balloon dilation were performed, and a plastic 7Fr stent was left in place (Figures 1-3). The patient was discharged home without complications. Due to the chronicity and length of the stricture, the decision was made to provide definitive treatment with an elective Roux-en-Y hepaticojejunostomy, which was scheduled three weeks after his ERCP.

At the time of the surgery, our patient was asymptomatic, and his total bilirubin had normalized to 0.9mg/dL. Upon entering the abdomen through a right subcostal incision, dense adhesions were encountered over the gallbladder, portal

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triad and duodenum. A Kocher maneuver was performed and revealed a dilated cystic duct and proximal common bile duct. The common bile duct was transected, and the distal end was oversewn. A cholecystectomy was performed, and a Roux-en-Y limb was created 15cms from the ligament of Treitz. The limb measured 45 cms in length. It was placed in a retrocolic position,

and an end-to-side hepaticojejunostomy was fashioned. The patient tolerated the procedure well and was discharged home on postoperative day seven. At discharge, he was tolerating a regular diet without symptoms of abdominal pain, nausea or vomiting. Follow up three weeks and again two months later found him asymptomatic, eating well with good weight gain and normal serum liver function tests, amylase and lipase.

DISCUSSIONBiliary injuries are quite rare following blunt abdominal

trauma in both children and adults. A recent, single institution review from 2002 through 2012 at a level 1 pediatric trauma center found an incidence of biliary injuries of only 0.09%(N=12/13,582) [2]. All patients had associated intra-abdominal injuries, most commonly to the liver, pancreas and duodenum. In this series, the injuries ranged from complete biliary duct transection to a biliary leak to the presence of a biloma without identifiable leak. These injuries were identified after approximately seven days following the trauma. Only three patients went on to develop biliary strictures. These strictures were diagnosed in the first month following the trauma, and a combination of multiple endoscopic and radiographic procedures was necessary for resolution. A similar experience is reported in the adult literature. Yoon et al. [3] reported a series of five patients with biliary strictures caused by blunt abdominal trauma. The interval between initial trauma and the onset of symptoms was 15-60 days (mean = 29 days). The stricture site was the suprapancreatic portion of the common bile duct in four patients and the intrapancreatic portion in one patient. The stricture lengths were 0.5-2.0 cms with a mean of 1.4 cms. All resolved following stent placement at the time of ERCP. More recently, Park et al. [4] reported on eight patients who became symptomatic an average of 23 days following blunt abdominal trauma. The median length of the biliary strictures was 1 cm.

Figure 1 Smooth, tapering distal common bile duct stricture with proximal dilation.

Figure 2 Balloon Sphincteroplasty.

Figure 3 Successful placement of 7Fr biliary stent.

Table 1: Laboratory Studies.

Test Value Normal Range

White blood count 7.1 K/mcL (4.5-13.5 K/mcL)

Hemoglobin 15.7 K/mcL (13-16 g/dL)

Platelet count 259 K/mcL (153-367 K/mcL)

Serum chemistries:

Sodium 140mmol/L (136-145 mmol/L)

Potassium 3.5mmol/L (3.5-5.1 mmol/L)

Chloride 100mmol/L (98-107 mmol/L)

Bicarbonate 27mmol/L (21-30 mmol/L)

Blood urea nitrogen 8 mg/dL (6-20 mg/dL)

Creatinine 1.0 mg/dL (0.42-0.92 mg/dL)

Glucose 99 mg/dL (70-99 mg/dL)

Amylase 62 units/L (27-131 units/L)

Lipase 322 units/L (<51 units/L)

AST 374 units/L (10-41 units/L)

ALT 827 units/L (17-63 units/L)

Total bilirubin 4.5 mg/dL (0.4-1.5 mg/dL)

Direct bilirubin 3.3 mg/dL (0.1-0.5 mg/dL)

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Endoscopic stent placement was corrective in all cases. The earliest documented cases in the literature presented similarly but occurred prior to the advent of ERCP and were treated with a Roux-en-Y choledocho jejunostomy [5,6].

Our patient’s biliary stricture was different from others reported in the literature. First, it became symptomatic much later at five months following the trauma, and the patient did not present for an additional two months. Second, the stricture was notably longer at 3 cms. We chose a staged, multidisciplinary approach for our patient. One of our authors [2] is quite experienced in ERCP as a treatment for bile leak following severe liver trauma [7]. We elected to stent the stricture initially as a temporizing measure, in order to provide symptom relief and nutritionally optimize our patient for a later definitive surgical repair with a Roux-en-Y hepaticojejunostomy. An alternative approach would have been to try to obtain resolution of a long, chronic stricture with repeated stent placements. Given the patient’s young age and excellent physical health, we elected to perform the definitive procedure, rather than embarking on multiple endoscopic procedures which likely would merely temporize but fail to resolve the problem.

Although ERCP is usually the first line of treatment in the management of biliopancreatic disease, additional surgical procedures are sometimes necessary. A Roux-en-Y Hepaticojejunostomy is the standard operative approach for extra-hepatic biliary injuries [8,9]. While the durability of this surgery in pediatric trauma patients is not well documented in the literature, it has excellent durability in babies and children with type I choledochal cysts [10,11]. Moreover, there is evidence in adult patients with biliary strictures secondary to chronic pancreatitis to support surgical hepatobiliary reconstruction over repeated endoscopic interventions [12].

In summary, traumatic extra-hepatic biliary injuries are rare in both the pediatric and adult populations. Exceedingly more rare are delayed biliary strictures requiring endoscopic and/or operative intervention. We describe here a successful combined approach for the management of a long, chronic distal common bile duct stricture secondary to blunt abdominal trauma. For this select patient population, we propose a multidisciplinary approach with an initial ERCP with sphincterotomy and stent placement to temporize the patient, followed by definitive

surgical management in order to offer the maximum benefits of both symptom relief and long-term durability.

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Cappiello CD, Darwin PE, Alaish SM (2015) A Chronic Biliary Stricture Following Blunt Abdominal Trauma. J Liver Clin Res 2(3): 1016.

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