Isolated Left Hepatic Duct Injury in Blunt Trauma Abdomen: Two Case Reports with Literature Review

Abstract

Isolated extrahepatic biliary tract injury following blunt abdominal trauma is rare. The underlying pathogenic mechanisms remain obscure, but include shear and/or compression forces on the biliary system. Associated morbidity rates are high and largely the result of delays in diagnosis. . The primary aim of this paper is to describe the clinical features, diagnosis, treatment, and outcome of two patients with left hepatic duct injury after blunt abdominal trauma. As a secondary objective, a literature review is presented. The two cases presented in this study are as follows: (1) A young male, involved in a crush injury by a motor vehicle, was referred with history of blunt hepatic trauma thirty days back and abdominal distension from a general hospital. His vitals were stable. Sonography of abdomen demonstrated a large fluid collection in upper abdomen. A percutaneous drain was placed in this collection and drained approximately 5000ml of bile. Due to continued drainage of several hundred millilitres of bile per day an Endoscopic retrograde cholangiography (ERCP) was obtained. This demonstrated a leakage at the left hepatic duct and stenting was done. Over the next several days, the drainage markedly decreased. A repeat ERCP was conducted 12 weeks later and stent was replaced. This further decreased bilious discharge to 20 ml/day for three days and then nil. Stent and drain was removed and patient was comfortably discharged and followed up. (2) A young male fell from a height. On exploratory laparotomy, hemoperitoneum, liver injury, retroperitoneal hematoma to the right with no biliary leak was noted at that time. 600ml/day bilious discharge was noted in drain from post-operative day 2. Endoscopic retrograde cholangiography was conducted 2 weeks later and revealed a large leakage at the left hepatic duct. Repeat exploratory laparotomy was performed and revealed left hepatic duct injury. Primary closure of left hepatic duct over t-tube was done. A high level of suspicion is necessary to identify injuries to the hepatic ducts. Early diagnosis that occurs during laparotomy due to associated injuries is important to reduce complications.