Challenges in management of an isolated intrapancreatic Common Bile Duct injury in an abdominal trauma

Abstract

Introduction: Biliary tract injuries are rare following abdominal trauma. If detected late, outcome is less favourable. It adds to morbidity if there is involvement of head of pancreas or duodenal wall.

Case report: We present a case of an adult male with sharp and blunt trauma over the right side of the abdomen with omentum protruding out. Exploratory laparotomy revealed non expanding paraduodenal hematoma without evidence of solid or hollow viscous injury. Post-operative day 2 drain showed bilious content. Contrast Enhanced CT scan ruled out the solid or hollow viscous injury. Magnetic Resonance choledocopancreaticography (MRCP) done on day 4 was suggestive of isolated intrapancreatic common bile duct injury of American Association of Surgery for Trauma (AAST) grade V. Endoscopic Retrograde choledocopancreaticography (ERCP) with stenting was done. Stent removal was done after 12 weeks. The patient is asymptomatic at 1 year follow up.

Discussion: Due to limitations of the conventional post trauma investigations like FAST and CECT abdomen, it is likely to miss the CBD injury in the early course. MRCP is a good noninvasive investigation to diagnose the biliary injury. ERCP is considered as the most appropriate tool for the diagnosis as well as therapeutic stenting.

Conclusion: High degree of suspicion is most important in diagnosis of the distal common bile duct trauma as imaging studies like FAST and CT scan can miss the same. MRCP is good noninvasive imaging tool to diagnose the biliary trauma, while ERCP is the best diagnostic and therapeutic tool with minimal post-operative morbidity.

Keywords: Abdominal trauma; Bile leak; Biliary injury; ERCP; Intra pancreatic bile duct injury; Stenting.

Fig. 1

Endoscopic Retrograde Cholangiopancreatography showing extravasation of the contrast from intrapancreatic common bile duct a. Pre-stenting b. Post-stenting.