Rupture of the common bile duct due to blunt trauma, presenting difficulty in diagnosis

Abstract

Rupture of the common bile duct because of blunt trauma is extremely rare. Preoperative diagnosis is very difficult because bile causes little peritoneal irritation. We present a case of a 19-year-old young woman with rupture of the common bile duct due to blunt trauma. She arrived at our hospital 1 hour after a car accident. She was diagnosed as pancreatic head injury, and conservative therapy was administered. It was effective, but after starting oral intake 6 days after the injury, she presented with abdominal fullness because of increased ascites. The ascites contained large amounts of bile. Rupture of the common bile duct became apparent, thus, she underwent emergency surgery 13 days after the injury. The common bile duct was ruptured completely at the lower bile duct. We repaired it by choledochojejunostomy. Her postoperative course was uneventful, and she discharged on the 12 days after the surgery. Preoperative drip-infusion-cholangiography-CT was useful for its diagnosis.

Background

Since Fizeau¹ reported traumatic rupture of the common bile duct followed by jaundice, this clinicopathological entity has been recognised as a syndrome characterised by initial onset of shock for a short duration, followed by a symptom-free interval and gradual appearance of abdominal pain, vomiting and jaundice.² Although this syndrome is fairly characteristic, it has not been always considered in abdominal trauma. Therefore, the patients sometimes suffer from the bile peritonitis.

Rupture of the common bile duct mostly occurs as a result of injury from a sharp instrument or from iatrogenic injury; therefore, the probability of it being caused by blunt trauma is extremely low.³

Here, we present a case surgical repair of rupture of the common bile duct due to blunt trauma.

Case presentation

A 19-year-old young woman was referred to our hospital for abdominal trauma related to a car accident. She drove a car and clashed with a guardrail while curving to the left because of looking away, thus, she hit her upper abdomen to the car-handle. She had a history of scoliosis. When she arrived at our hospital 1 hour after the accident, she had generalised abdominal pain, and an abdominal guarding sign was noted on physical examination. Thus, we performed detailed examination.

Investigations

Vital signs were: blood pressure 110/71 mm Hg, heart rate 66 beats/min, respiratory rate 20 breaths/min and SpO₂ 100% (O₂: 10 L). Her consciousness was alert. Laboratory test revealed elevated white blood cell (WBC) counts (18.1×10⁹/L) and serum aspartate transaminase (AST) and alanine aminotransferase (ALT) levels; however, the serum amylase (Amy) level was within the reference range. Haemoglobin level was 12.7 g/dL and there was no jaundice (table 1).

Table 1.

Laboratory data on admission

WBC	18 100/µL	ALT	103 IU/L
RBC	418×104/µL	ALP	257 IU/L
Hb	12.7 g/dL	Amy	133 IU/L
Ht	38.5%	BUN	11 mg/dL
Plt	33×104/µL	Cr	0.69 mg/dL
T-Bil	0.5 mg/dL	CK	123 IU/L
AST	212 IU/L	CRP	0.06 mg/dL

ALT, alanine aminotransferase; AST, aspartate transaminase; Hb, haemoglobin; Plt, platelet; RBC, red blood cell; WBC, white blood cell.

Other haematological and biochemical parameters were almost within normal limits. Enhanced CT of the arterial phase revealed extravasation from peripheral branch of the inferior pancreaticoduodenal artery (IPDA) (figure 1A) and that of the portal phase revealed pancreatic head swelling, which was considered a haematoma of the pancreas (figure 1B). However, MR cholangiopancreatography (MRCP) showed no signs of rupture of the main pancreatic duct or the common bile duct (figure 2).

Figure 1.

(A) Abdominal enhanced CT on admission showed extravasation from pancreaticoduodenal arcade (arrow). (B) The CT revealed enlargement and haematoma in the pancreatic head (arrow).

Figure 2.

MR cholangiopancreatography on admission showed poor rendering of the bile duct.

Treatment

Based on CT and MRCP findings, we diagnosed her as pancreatic head injury. As her vital signs were stable and her general clinical condition was relatively good, we planned to start conservative treatment. Abdominal pain and laboratory data got improved 6 days after the injury (WBC 7.5×10⁹/L), and the patient started oral intake. However, 3 days after she started oral intake, she developed vomiting, abdominal fullness and severe ascites. We performed ascites tapping and found an extremely high level of bilirubin in the ascitic fluid (46 mg/dL), along with amylase (71 mg/dL). Bile duct injury was suspected, thus, we performed endoscopic retrograde cholangiopancreatography (ERCP). There was no main pancreatic duct injury. Bile duct cannulation was not achieved, and cholangiography was unsuccessful (figure 3). Then, we added drip-infusion-cholangiography-CT (DIC-CT). The contrast agent was leaked from the lower common bile duct to the ventral side and the rupture of lower bile duct was suspected. The ruptured stump seemed to deviate to the right side (figure 4). Under the diagnosis of the common bile duct injury due to blunt trauma, we decided to perform surgical treatment 13 days after her admission. The detail of surgical treatment is as below. We started with exploratory laparoscopy. Intraperitoneal was full of bile ascites, and the intraoperative cholangiography showed the point of rupture of the common bile duct and the stump, which was deviated towards the right side (figure 5A). We shifted to open surgery. Following duodenum mobilisation, we detected a completely ruptured upper side of stump of the common bile duct (figure 5B). The lower stump of the bile duct was not detected, and we thought that the intrapancreatic bile duct was ruptured. We performed choledochojejunostomy at the upper side of the ruptured bile duct. We tried to repair lower side of the ruptured bile duct, but we could not detect it, thus, we did not close lower side of the ruptured bile duct. We placed four abdominal drains and operation was completed. The operation time was 384 min and the amount of blood loss was 257 mL.

Figure 3.

Endoscopic retrograde cholangiopancreatography on 9 days after the injury revealed no signs of injury in main pancreatic duct, but bile duct cannulation was unsuccessful (arrow heads).

Figure 4.

Drip-infusion-cholangiography-CT on 12 days after the injury revealed contrast agent leaked out from the bile duct to the abdominal cavity (arrow heads).

Figure 5.

(A) Operative cholangiographic findings. Contrast agent through the cystic duct leaked out (asterisk) from the lower common bile duct (arrow heads). (B) Intraoperative findings. The upper stump of the bile duct was detected but the lower stump of the bile duct was not seen (arrow).

Outcome and follow-up

The postoperative course was good. She presented no complications including pancreatic fistula or bile leakage, thus she was discharged on the 12th postoperative day. The postoperative course after discharge from our hospital was also good without any complications, and we ended her follow-up one and a half year after the surgery.

Discussion

Rupture of the common bile duct was first reported in 1806 by Fizeau.¹ Most of the reported cases resulted from injuries caused by sharp instrument injury or iatrogenic injury; thus, the probability of common bile duct rupture being caused by blunt trauma is extremely low.³ Posner and Moore⁴ reported that common bile duct injury accounted for less than 1% of all abdominal injury. Rydell⁵ reported that the incidence of common bile duct rupture is only 25 cases of the 91 cases of injuries to common bile duct reported over 80 years. We conducted a PubMed search using ‘trauma’, ‘common bile duct’ and ‘rupture’ as keywords and retrieved seven case reports^6–11 on rupture of the common bile duct caused by blunt trauma, written in English (table 2).

Table 2.

Summary of reported cases of rupture of the common bile duct

Case	Authors	Year	Age	Sex	Position of the injury	Pattern of the injury	Diagnosis procedure	Time until treatment	Operative procedure
1	Dobbie and Stormo6	1968	27	M	Transitional zone of pancreas	Traffic accident	Intraoperative finding	12 hours	Place T tube
2	Caro and Losa7	1970	3	M	Intrapancreatic bile duct	Metal bar fall	Intraoperative finding	12 hours	Choledochoduodenostomy
3	Balsano and Reynolds8	1973	21	M	Intrapancreatic bile duct	Traffic accident	Intraoperative finding	1.5 hours	Choledochoduodenostomy
4	Balsano and Reynolds8	1973	30	M	Intrapancreatic bile duct	Traffic accident	Intraoperative finding	Unknown	Choledochoduodenostomy
5	Barry et al 9	1992	52	F	Intrapancreatic bile duct	Kick from horse	Intraoperative finding	Unknown	Choledochoduodenostomy
6	Depolo et al 10	1999	31	M	Intrapancreatic bile duct	Traffic accident	Intraoperative finding	Unknown	Choledochojejunostomy
7	Balzarotti et al 11	2012	16	F	Common hepatic duct	Traffic accident	Bile leak from surgical drain	13 days	Place T tube
8	Our case		19	F	Intrapancreatic bile duct	Traffic accident	Ascites aspiration	13 days	Choledochojejunostomy

The mean patient age was 25.7 years (3–52 years), the male to female ratio was 1:0.4, and the mean interval from the onset of injury until the surgical treatment was about 3.5 days (1.5 hours –13 days). The cases without CT scan underwent exploratory laparotomy rapidly.

The generation mechanism was considered as below, (1) compression opinion,¹² (2) opinion on elevation of pressure in bile duct,^{13 14} (3) extension opinion¹⁵ and so on. In this case, we think following might have happened; the car-handle crashed to her upper abdomen and the liver was compressed to cranial side, and inertial force because of the loss of speed at the collision brought the bile duct out to ventral side. After that, the bile duct detached from the transitional zone of pancreas. Mohardt¹⁵ and Ito et al ¹⁶ reported similar generation mechanism for the injury caused by ‘deceleration force’. This type of injury has often been observed in cases of the rupture of common bile duct at transitional zone of pancreas, perforation of horizontal part of duodenum and injury of extra hepatic duct.^{5 16} However, there is another possibility of aetiology, ischaemia may lead to common bile duct rupture. Extravasation from IPDA and haematoma of pancreatic head may contribute to delayed common bile duct rupture.

Symptoms caused by the common bile duct rupture are often slight at the initial stage of the injury, and the symptoms like spontaneous pain or pressure pain at right hypochondrium may improve in about 2 days. Later, in about 5 days, jaundice and abdominal fullness due to bilious peritonitis gradually appear.¹⁷ Signs of peritoneal irritation like severe abdominal pain or muscular guarding are not usually apparent.¹⁸ In this case, the pain was getting better after admission and the value of bilirubin was under 2 mg/dL until 3 days after the injury. However, abdominal fullness appeared gradually 4 days after the injury.

Regarding diagnosis, since bile causes little peritoneal irritation, the symptoms are hard to recognise and diagnosis is often delayed. Michelassi and Ranson¹⁹ reported that the cases of delayed diagnosis are up to 50% of the total, and there is a report that the whole process takes average 18 days from the appearance of symptoms to surgical treatment.¹² Definitive diagnosis of injury of biliary system requires ascites aspiration and detection of bile ascites.¹⁸ However, in case with duodenum injury, as bile leaks from the ruptured common bile duct and the duodenum, definitive diagnosis of rupture of the common bile duct is difficult.³ In our case, it took 10 days from the injury to diagnose bilious peritonitis, confirmed by ascites aspiration, and took three more days to perform the surgery. DIC-CT was very useful to evaluate the bile duct injury.

Regarding the treatment, when the injury is over the half diameter of the bile duct, primary closure is usually difficult.²⁰ Choledochojejunostomy and hepaticojejunostomy (Roux-en-Y reconstruction) are safe reconstruction methods, because these procedures have least chances to cause stenosis after operation.²¹ Depolo et al ¹⁰ reported that in case of the injury at the pancreatoduodenal junction with high degree of destruction, there is a need to perform pancreaticoduodenectomy (Whipple), and in case of rupture of the bile duct situated in the intrapancreatic portion, there is a need to perform a choledochojejunostomy (Roux- en Y reconstruction). Besides, in case of rupture of common bile duct at transitional zone of pancreas, detecting the lower stump of bile duct is sometimes difficult.¹³ Turney et al ²² reported that the lower stump of the ruptured bile duct could be detected in only nine of 16 cases. In our case, it was impossible to detect the lower stump of the ruptured common bile duct as the injury site was lower than the transitional zone of the pancreas. In preoperative imaging, there was little information about the duodenal side of the stump, and ERCP, DIC-CT and MRCP had also no information about the lower bile duct below the point of rupture. Therefore, we performed choledochojejunostomy for liver side of the stump. Although, there was a possibility of late complication because of the opening of the lower bile duct stump, post-discharge course was good and no abdominal symptoms appeared for over 1.5 years in our case. Therefore, we think that our surgical treatment was appropriate for this case.

Learning points.

• Rupture of the common bile duct due to blunt trauma is extremely rare.

• Symptoms of the common bile duct rupture are often mild at the initial stage, and can gradually become obvious later.

• Drip-infusion-cholangiography-CT, MR cholangiopancreatography and endoscopic retrograde cholangiopancreatography are useful to its diagnosis.

• Bile duct reconstruction, such as choledochojejunostomy and hepaticojejunostomy are usually required.