Which type of Strasberg Bismuth classification for biliary (bile) ductal injury will appear normal on Endoscopic Retrograde Cholangiopancreatography (ERCP)?

Strasberg Type A Bile Duct Injury Will Appear Normal on ERCP

Type A injuries in the Strasberg-Bismuth classification will appear normal on ERCP examination because they involve bile leaks from minor ducts in the liver bed or cystic duct stump that do not affect the main biliary tree. 1

Understanding the Strasberg-Bismuth Classification

The Strasberg-Bismuth classification categorizes bile duct injuries (BDIs) into five main types:

• Type A: Bile leaks from cystic duct stump or minor ducts in the liver bed (ducts of Luschka)
• Type B: Occlusion of part of the biliary tree
• Type C: Transection without ligation of aberrant right hepatic duct
• Type D: Lateral injury to major bile ducts
• Type E (1-5): Major injury to common hepatic or common bile duct 2, 1

Why Type A Injuries Appear Normal on ERCP

Type A injuries present a unique diagnostic challenge because:

1. The main biliary tree structure remains intact and appears normal on cholangiography
2. The injury involves peripheral structures (cystic duct stump or ducts of Luschka) that may not be directly visualized during ERCP
3. The only indication of injury may be contrast extravasation from these peripheral structures 1

Diagnostic Considerations

When evaluating a patient with suspected bile duct injury:

• A normal-appearing biliary tree on ERCP does not exclude a Type A injury
• Clinical suspicion should be maintained when symptoms suggest bile leak despite normal ERCP findings
• Type A injuries account for approximately 46.4% of bile duct injuries, making them the most common type 3
• Additional diagnostic clues include:
  • Bile in surgical drains
  • Biloma formation
  • Elevated liver function tests
  • Signs of biliary peritonitis 1

Management Approach for Type A Injuries

Despite appearing normal on ERCP, Type A injuries require appropriate management:

1. Initial approach: Observation with drainage if a drain is already in place
2. If leak persists: ERCP with biliary sphincterotomy and stent placement becomes mandatory
3. Success rate: ERCP with stenting is highly effective for Type A injuries, with success rates approaching 90% 2, 1, 3

Clinical Implications

Understanding that Type A injuries appear normal on ERCP has important clinical implications:

• Clinicians must not mistake a normal-appearing biliary tree as absence of injury
• Type A injuries may present days after surgery with biliary peritonitis or biloma
• ERCP serves as both a diagnostic and therapeutic tool by reducing the pressure gradient in the biliary tree, facilitating healing 2, 1

Pitfalls to Avoid

• Relying solely on ERCP appearance to rule out bile duct injury
• Delaying intervention when clinical signs suggest bile leak despite normal ERCP
• Failing to consider additional imaging modalities like MRCP with hepatobiliary contrast agents when clinical suspicion remains high 2

By recognizing that Type A injuries appear normal on ERCP, clinicians can avoid diagnostic delays and provide appropriate management for these common bile duct injuries.