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

Strasberg Type A Bile Duct Injury Appears Normal on ERCP

Type A injuries in the Strasberg-Bismuth classification system will appear normal on ERCP because the main biliary tree structure remains intact. 1

Understanding Strasberg-Bismuth Classification and ERCP Findings

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

• Type A: Bile leaks from the 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 ducts 1

Type A injuries present a unique diagnostic challenge because:

• The main biliary tree structure remains intact
• The biliary anatomy appears normal on cholangiography (ERCP)
• The injury is only detected by contrast extravasation from the cystic duct stump or liver bed during ERCP 1

Diagnostic Characteristics of Type A Injuries

Type A injuries are characterized by:

• Normal-appearing main biliary tree on ERCP
• Bile leaks from peripheral ducts (cystic duct stump or ducts of Luschka)
• Clinical presentation with bile leak, biliary peritonitis, or biloma formation
• Elevated liver function tests and inflammatory markers 1

In contrast, other injury types (B-E) show abnormalities on ERCP:

• Type B: Shows occlusion of part of the biliary tree
• Type C: Shows missing right hepatic duct
• Type D: Shows lateral defect in major bile ducts
• Type E: Shows various levels of transection/stricture of the main bile ducts 1, 2

Clinical Relevance and Management Implications

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

• When ERCP findings are normal but clinical suspicion for bile leak remains high, additional imaging with MRCP combined with hepatocyte-specific contrast agents or hepatobiliary scintigraphy should be considered 1
• For Type A injuries, ERCP with biliary sphincterotomy and stent placement is highly effective, with success rates approaching 90% 1, 3
• Initial management may include observation with drainage if a drain is already in place, but if the leak persists, ERCP with intervention becomes mandatory 1

Common Pitfalls and Caveats

• Diagnostic challenge: Normal ERCP findings may falsely reassure clinicians despite an ongoing bile leak from Type A injury
• Limited visualization: ERCP alone may not detect peripheral leaks if contrast doesn't extravasate during the procedure
• Need for complementary imaging: When ERCP appears normal but clinical suspicion remains high, additional imaging with MRCP or hepatobiliary scintigraphy is necessary 1
• Delayed presentation: Most bile duct injuries (89.3%) are diagnosed postoperatively rather than intraoperatively, highlighting the importance of maintaining clinical suspicion despite normal initial imaging 3

Remember that Type A injuries represent a significant proportion of bile duct injuries (46.4% in one series) and require specific management approaches despite their normal appearance on ERCP 3.