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Imaging and Management of Biliary Injuries


KEY FACTS

Imaging

  • Biliary injuries are increasing in frequency

    • Imaging plays crucial role in identification & management

  • Direct Cholangiography

    • ERCP is best for evaluation of injury to major hepatic duct branches & CBD

      • –

        Also guides therapeutic intervention (sphincterotomy & stent placement)

  • CT : Accurately depicts presence and extent of hepatic parenchymal injuries

    • Active bleeding is accurately depicted

    • Hepatic arterial (HA) occlusion may be depicted or suggested

    • Injuries to GB & bile ducts are suggested only indirectly

      • –

        Presence of lower density (attenuation) fluid in GB fossa & peritoneal cavity

  • Eovist (Primovist) enhanced MR

    • Valuable in evaluation of patients with known or suspected biliary injuries

    • Superior to hepatobiliary scintigraphy (greater anatomic detail & spatial resolution)

  • Hepatobiliary Scintigraphy

    • Variations of Tc-99m "HIDA" scan (hepatobiliary iminodiacetic acid)

    • Look for extraluminal collections (bile leak) on sequential images over 60-120 minutes

    • SPECT (single photon emission computed tomography): Greater anatomic detail & spatial resolution

  • Provides greater anatomic detail & spatial resolution than conventional planar imaging due to tomographic sections

  • Recommended imaging protocol

    • CT is optimal for initial evaluation of hepatobiliary injuries

    • Hepatobiliary scintigraphy is useful when clinical suspicion of biliary injury is relatively low

    • MR with MRCP and gadoxetate enhancement is optimal noninvasive test when clinical suspicion is high

    • ERCP or PTC is most accurate for diagnosis and guidance for therapy

In this patient, injured in a motor vehicle crash, CT shows a deep hepatic laceration
and free intraperitoneal fluid
that was less dense than blood.

In the same case, CT shows clotted blood
and lower density fluid in the gallbladder fossa, as well as a heterogeneous lesion
in the groove between the pancreatic head and 2nd portion of the duodenum, suggesting a traumatic injury.

The same patient developed abdominal pain and a suggestion of peritonitis. Concern about a biliary injury prompted transhepatic cholangiography (PTC), which showed transection of the distal common bile duct within the pancreatic head, and extravasation of bile
.

A 2nd image from the same PTC shows further accumulation of opacified bile
. This was treated with open choledochoenteric anastomosis. (Contrast-opacified urine is present in the kidney
from the preceding CT scan.)

IMAGING

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