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

Strasberg-Bismuth Classification: Type A Injuries Appear Normal on ERCP

Type A injuries in the Strasberg-Bismuth classification 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
• Diagnosis is made by observing contrast extravasation from the cystic duct stump or liver bed during ERCP 1

Diagnostic Implications

When evaluating a patient with suspected bile duct injury after cholecystectomy:

1. In Type A injuries, ERCP will show a normal biliary tree structure but may demonstrate contrast extravasation from the cystic duct stump or liver bed 1, 2
2. For Types B-E, ERCP will show abnormal findings such as strictures, occlusions, or transections 1
3. Type A injuries commonly present as biliary fistula and bile leaks (46.4% of bile duct injuries in one study) 2

Clinical Relevance and Management

For Type A injuries that appear normal on ERCP:

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

For more complex injuries (Types B-E):

• Additional imaging modalities like MRCP or PTC may be necessary for complete evaluation 1
• Surgical management with hepaticojejunostomy is typically required for major injuries 3

Important Caveats

• When ERCP findings are normal but clinical suspicion for bile leak remains high, consider:
  • MRCP with hepatocyte-specific contrast agents (accuracy close to 100% for detecting bile leaks)
  • Hepatobiliary scintigraphy (more sensitive and specific than ultrasound or CT) 1
• Type A injuries may be missed on initial ERCP if the leak is intermittent or small
• Clinical presentation with biliary peritonitis, biloma formation, or elevated liver function tests should raise suspicion even with normal ERCP findings 1