A 19-year-old male presented with a road traffic accident injury involving blunt trauma to the abdomen. On examination, he had signs of liver and possible bile duct injury. Imaging revealed a laceration in segments V, VI, and VII of the liver along with hemoperitoneum. The patient underwent surgery where buttress sutures were applied to the liver laceration and packing was done. Post-operatively, the patient developed a bile leak. ERCP revealed a lateral rent in the common bile duct, which was stented successfully. The patient's bile leak resolved and he was discharged four days later.

1. Case Presentation
Dr Mohammad Tallal Abdullah
Post Graduate Resident
Surgical Unit ll
SHL

2. History
• A 19 year old male
• Presented in surgical emergency with history
of road side accident about 3 hrs back
• Patient was riding on bike
• Hit by a Mazda loader from the side and was
dragged along the vehicle for some distance
on road

3. Physical examination
• Pulse 100 bpm
• B.P 90/60
• R/R 22 /min
• O2 sat 95%
• Airway was clear
• C-spine was intact
• Relatively reduced air entry on right side of chest
with subcutaneous emphysema
• Imprint sign over right hypochondrium

4. • Abdomen was tender and tense with positive
guarding sign
• Pelvis stable
• All four limbs normal
• There was no obvious bleeding seen at the
time of presentation
• There were no signs and symptoms of head
injury
• Patient had a GCS of 15/15 and was
responding to verbal commands

5. Management
• Chest intubation
• Main goal: Resuscitation
• 2 wide bore IV lines
• I/V Fluids rushed
• I/V Analgesia
• Anti tetanus toxoid
• I/V Antibiotic
• Nasogastric tube
• Catheterization
• Vitals monitoring

6. Workup
• CBC: Hb 11.5
TLC 15,000
• RFTs: ALT 60
• Other baseline investigations unremarkable
• blood grouping and cross matching
• CXR
• FAST scan (moderate amount of fluid in
abdomen and pelvis)
• urine examination
• CT scan

12. LIVER TRAUMA

13. • Liver is one of the most commonly injured
organs in abdominal trauma.
• Most common cause is blunt abdominal
trauma which is usually as a result of RTA.
• Liver trauma can either be due to:
#Blunt abdominal trauma
#Penetrating abdominal trauma
#Iatrogenic

14. Grading Of Traumatic Liver Injury
Traumatic liver injury can be graded according to
either:
-hepatic hematoma
-or hepatic laceration
And at worse, major vascular injury/avulsion is
graded as grade 6

15. Grade I
Hematoma: Subcapsular, nonexpanding, < 10% surface area.
Laceration: Capsular tear, nonbleeding, < 1cm deep.
Grade II
Hematoma: Subcapuslar, nonexpanding, 10-50% surface area; intraparenchymal, nonexpanding,
< 2cm diameter.
Laceration: Capsular tear, active bleeding; 1-3cm deep, < 10cm in length.
Grade III
Hematoma: Subcapsular, > 50% surface area or expanding; ruptured subcapsular hematoma
with active bleeding.
Laceration: Intraparenchymal hematoma > 2cm or expanding; > 3cm deep.
Grade IV
Hematoma: Ruptured intraparenchymal hematoma with active bleeding.
Laceration: Parenchymal disruption involving 25-50% of hepatic lobe.
Grade V
Laceration: Parenchymal disruption involving > 50% of hepatic lobe.
Grade VI
Vascular: Juxtahepatic venous injury; ie. Retrohepatic vena cava / major hepatic veins, hepatic
avulsion.

16. Grade I
Hematoma: Subcapsular, nonexpanding, < 10% surface area.
Laceration: Capsular tear, nonbleeding, < 1cm deep.

17. Grade II
Hematoma: Subcapuslar, nonexpanding, 10-50% surface area;
intraparenchymal, nonexpanding, < 2cm diameter.
Laceration: Capsular tear, active bleeding; 1-3cm deep, < 10cm
in length.

18. Grade III
Hematoma: Subcapsular, > 50% surface area or expanding; ruptured
subcapsular hematoma with active bleeding.
Laceration: Intraparenchymal hematoma > 2cm or expanding; > 3cm deep.

19. Grade IV
Hematoma: Ruptured intraparenchymal hematoma with active bleeding.
Laceration: Parenchymal disruption involving 25-50% of hepatic lobe.

20. Grade V
Laceration: Parenchymal disruption involving > 50% of hepatic
lobe.

21. Management
Conservative
• Hemodynamically
stable patients with
abdominal trauma with
mild to moderate grade
of liver injury (1-3)
• Hollow viscus injuries
must have been ruled
out
Surgical
• Hemodynamically
unstable patients with
deterioration during
observation
• All grade 4 and above
hepatic injuries
• Gunshot or stab wound
with penetration of
peritoneum

22. Surgical options
• Exploratory laparotomy is done and primary
focus is to secure hemostasis. 4 P’s
• ‘Push’. Traumatized liver is manually closed
• ‘Pringle’. Hemostatic clamp over hepatoduodenal
ligament
• ‘Plug’. Any penetrating injury to liver can be
plugged.
• ‘Pack’
• Other options include hepatotomy, suturing,
parenchymal resection, vascular repair and
ligation

23. Back to case….

24. • Exploratory laparotomy done revealing:
i. 1.5 litre hemoperitoneum
ii. Laceration of hepatic segment V, Vl, Vll,
iii. Suspicion of biliary leakage
Buttress sutures applied to the major segment
Vl laceration And Liver Packing was done…
3 pints of whole blood transfused peroperatively
Patient shifted to SICU on ventilator where he
remained hemodynamically stable

25. • Packs removed after 48 hours. Hemostasis was
secured.
• There was evidence of biliary leakage but
exact site couldn’t be identified…
A subhepatic drain was placed then..

26. Patient had a drain output averaging 100-150 ml
each day. Yellow in color
With persistent C/O pain epigastrium associated
with nausea.
Recurrent episodes of fever not settling with
antibiotics.

27. BILIARY FISTULA

28. Biliary Fistula
• The most common accepted definition of a bile
leak requires the presence of the following:
– bile discharge from an abdominal wound and/or
drain, with a total bilirubin level of >5 mg/mL or three
times the serum level
– intra-abdominal collections of bile confirmed by
percutaneous aspiration
– cholangiographic evidence of dye leaking from the
opacified bile ducts
World Journal of Surgery, vol. 27, no. 6, pp. 695–698, 2003.

29. ETIOLOGY
• Bile leaks mainly result from injury to the
extrahepatic bile duct during cholecystectomy.
• A bile leak from the intrahepatic biliary tree is
less frequent and generally follows liver surgery
• After blunt or penetrating abdominal trauma
• Less commonly, bile leaks from the liver may
result following drainage of a liver abscess or
nonsurgical ablation of liver lesions / hydatid
cysts.

30. Natural Progression
• Most bile leaks settle spontaneously
• Others will settle with interventions such as
ERCP.
• Only a few require surgical management in
the form of hepaticojejunostomy.

31. Types
• Nagano et al. have classified postoperative bile
leaks into four types :
• Type A: minor leaks from small bile radicles on
the surface of the liver which are usually self-
limiting,
• Type B: leaks from inadequate closure of the
major bile duct branches on the liver’s surface,
• Type C: injury to the main duct commonly near
the hilum,
• Type D: leakage due to a transected duct
disconnected from the main duct.

32. Management - Overview
• Type A leaks usually close spontaneously with
external drainage although sometimes ERCP and
sphincterotomy may be required.
• Types B and C can be managed by ERCP and
stenting combined with drainage of the bile
collection.
• Type D leaks require surgery and bilioenteric
anastomosis or, if the draining segment is small,
fibrin glue occlusion or acetic acid ablation.
Sometimes operative excision of the excluded
segment may be required [10,11].

33. Bile leaks after liver trauma –
(Non-iatrogenic)
• Overall the incidence of intrahepatic bile duct
injury after blunt trauma for all grades of
injury varies from 2.8% to 7.4%
• Bile leaks can lead to significant morbidity
after liver trauma.
• Influx of bile into the hematoma may increase
the pressure within it, leading to necrosis of
the surrounding liver tissue and formation of a
biloma

34. • 2/3rd of patients with blunt abdominal trauma
requiring surgery develop bile leaks
• Of those managed conservatively only 17%
develop bile leaks.

35. Management
• Most cases of bile duct injury after blunt
trauma present as bilomas which can be
managed conservatively.
• Rest can be managed by ERCP
• Bile peritonitis which requires laparotomy and
drainage may also be managed by a minimal
invasive combination of laparoscopic lavage
and ERCP decompression
• Surgery is required only for type D fistulas.

36. Coming back to our case

37. • ERCP with stenting was done.
• A bile leak from a lateral rent in CBD was
noted.
• A stent was passed across the laceration.
• Patients was successfully managed and
discharged 4 days after ERCP.