Traumatic Biliary Stricture

Introduction and Case Report

Introduction

Traumatic bile duct injuries usually present clinically as bile leaks. Less commonly, trauma to the bile duct can result in a biliary stricture. Because these injuries tend to be subtle, they may go unrecognized at the time of injury. Patients may have a delayed presentation of jaundice with or without abdominal pain, and such strictures may be mistaken for malignancy. We present the case of a traumatic biliary stricture manifesting as painless jaundice more than 1 year after the initial injury.

Case Report

A 48-year-old man with a history of short-gut syndrome presented with painless jaundice. Approximately 1 year earlier he was involved in a motor vehicle accident in which he suffered a liver laceration and aortic dissection. Due to the aortic dissection, he suffered massive intestinal infarction and the majority of his small bowel was resected, leaving him with approximately 60 cm of small intestine and a jejunocolonic anastomosis. He was initially dependent on total parenteral nutrition. For the last several months prior to presentation, however, he was able to meet his caloric needs enterally and was only receiving intravenous fluids.

His medical history prior to the accident was unremarkable. Sequelae from the accident included short-gut syndrome, adrenal insufficiency, acquired pernicious anemia, depression, and atrial fibrillation. His medications included cholestyramine, codeine, bismuth subsalicylate, prednisone, fludricortisone, vitamin B₁₂, escitalopram, and loperamide. He did not drink alcohol.

The patient was noted to be jaundiced by his visiting nurse. He had vague symptoms of weakness and lethargy which had been present since his accident. He had not lost weight and his appetite had not changed. Other than obvious jaundice, physical examination was unremarkable. Initial laboratory findings were as follows: total bilirubin, 8.7 mg/dL (normal range, 0.2–1.2 mg/dL); direct bilirubin, 6.5 mg/dL (normal range, 0.1–0.3 mg/dL); aspartate aminotransferase, 153 IU/L (normal range, 9–30 IU/L); alanine aminotransferase, 395 IU/L (normal range, 7–52 IU/L); and alkaline phosphatase 280 IU/L (normal range, 36–118 IU/L). Hepatitis serologies (for A, B, and C) were negative.

Abdominal computed tomography (CT) scan was remarkable for extra- and intrahepatic biliary ductal dilation (Figure 1). There was no mass in the head of the pancreas (Figure 2). He underwent magnetic resonance cholangiopancreatography (MRCP), which revealed a stricture in the distal 1.7-cm segment of the common bile duct (CBD; Figure 3). The CBD proximal to the stricture was dilated up to 14 mm. No masses were identified within the pancreatic head. He was scheduled for an endoscopic retrograde cholangiopancreatography (ERCP) for further evaluation and treatment.

Figure 1.

Intra- and extrahepatic biliary ductal dilation.

Figure 2.

No masses seen in the head of the pancreas.

Figure 3.

MRCP demonstrating 1.7-cm stricture (stricture length demonstrated by double-headed arrow).

ERCP Findings and Management

At ERCP, the major papilla was normal. Cholangiography revealed a high-grade discrete stricture in the mid-CBD (suprapancreatic portion; Figure 4). A 0.025-inch straight Glidewire (Boston Scientific Endoscopy; Natick, Massachusetts) was passed into the biliary tree. A 5-French catheter could not be advanced over the wire across the tight stricture. Therefore, dilation with the 7-French Soehendra stent retriever (Cook Medical; Winston-Salem, North Carolina) was performed to “screw” across the stricture and was successful (Figure 5).

Figure 4.

Suprapancreatic biliary stricture (thick arrow) with normal pancreatogram (thin arrow).

Figure 5.

Passage of the Soehendra stent retriever used to “screw” across the stricture.

After dilation, the cytology brush catheter passed easily through the area of the stricture, suggesting that the stricture was fibrotic. The stricture was brushed for cytology and a 10-French, 7-cm long plastic biliary stent was placed across the stricture (Figure 6). Dark bile flowed through the stent immediately. Brushings revealed inflammatory cells and benign-appearing ductal cells. The patient made an uneventful recovery and will return for further endoscopic therapy.

Figure 6.

Stent placement across stricture.

Discussion

A wide spectrum of disorders can cause benign biliary strictures, including inflammatory diseases (eg, primary sclerosing cholangitis), choledocholithiasis, pancreatitis, iatrogenic injury, and noniatrogenic injury. Benign biliary strictures can also occur at the anastomosis following liver transplantation.[1] Iatrogenic biliary strictures are usually the result of complications related to cholecystectomy. Although much less common, iatrogenic strictures resulting from radiation and radiofrequency ablation have also been reported.[1, 2] Noniatrogenic biliary strictures are usually the result of external trauma.[1]

Traumatic biliary strictures are rare. A retrospective study examining endoscopic treatment of traumatic biliary strictures, using a database containing more than 14,000 ERCPs, identified 11 patients with biliary strictures associated with blunt abdominal trauma.[3] Another case series revealed an incidence of 5 biliary strictures due to blunt abdominal trauma out of more than 5000 ERCPs performed.[4] The possible causes of traumatic biliary strictures are unclear, but several mechanisms have been proposed: (1) a small tear in the bile duct induces inflammation (pericholangitis), which eventually leads to fibrosis and stricture; (2) the formation of intramural hematoma compresses the bile duct; (3) ischemia[3–6]; and (4) neuroma.[7]

Because the initial bile duct injury may not be apparent and because scarring and stricture formation take time, clinical presentation is often delayed. In 2 case series, the mean time between injury and presentation was 23 days[3] and 29 days,[4] but the delay can be even longer. Our patient presented more than 1 year after his initial trauma. Generally, patients present with painless jaundice, although they may complain of vague right upper quadrant pain. Because patients present with painless jaundice, there is often a high suspicion for malignancy; other authors have reported a traumatic biliary stricture mimicking a Klatskin tumor.[8] This underscores the importance of obtaining a thorough history of any abdominal trauma, which sometimes may be subclinical.

The diagnosis is suspected by appropriate abdominal imaging and CT scan findings that typically reveal a dilated biliary system without a pancreatic mass. Depending on the site of injury, MRCP may reveal a suprapancreatic biliary stricture and a normal pancreatogram. These findings are nonspecific, but a clinical history of blunt abdominal trauma can raise the index of suspicion for biliary stricture.[3,4] In one case series, most ERCPs demonstrated a suprapancreatic bile duct stricture and a normal pancreatogram.[3] The average length of biliary strictures due to trauma is approximately 1–1.5 cm.[3,4] Brushings of the stricture typically reveal benign epithelial cells, fibroblasts, and inflammatory cells.[4]

Traumatic bile duct strictures have been managed very successfully with percutaneous drainage[9,10] and endoscopic stenting.[3,4] In the 2 case series involving 13 patients, all of the patients were managed with endoscopic stenting and none required surgery.[3,4] In 12 of 13 patients, there was complete resolution of the stricture after stent removal and only 1 patient required repeat stenting.[3,4] Occasionally, as in our case, the stricture may be difficult to cross due to scar tissue, and a catheter or dilating catheter may be too soft to cross the fibrotic stricture. In these situations (and in our case), use of a Soehendra stent retriever has been successful in safely boring across the stricture.[11] Alternatively, small catheter wire-guided angioplasty balloons have also been used with success.[12] Overall, success rates with endoscopic stenting are excellent and surgical intervention is rarely necessary.

Conclusion

Traumatic biliary strictures are rare. Because of the subtle nature of the initial injury, the clinical presentation is often delayed. The most common presentation is painless jaundice and, as a result, these patients are often thought to have a pancreatic or biliary malignancy. The findings on abdominal imaging are nonspecific. Typical findings are a suprapancreatic biliary stricture and benign brushings. A history of blunt abdominal trauma can aid in confirming the diagnosis. Endoscopic stenting has an excellent success rate in managing biliary stricture due to blunt abdominal trauma.