Strasberg Type B Bile Duct Injury Will Appear Normal on ERCP
In the Strasberg-Bismuth classification of biliary ductal injuries, Type B injuries will appear normal on ERCP because they involve occlusion of part of the biliary tree that is not in continuity with the main biliary system. 1
Understanding the Strasberg-Bismuth Classification
The Strasberg-Bismuth classification is one of the most widely used systems for categorizing bile duct injuries (BDIs) that occur during laparoscopic cholecystectomy. This classification helps guide management decisions and predict outcomes 1.
The key types in the Strasberg classification include:
Type A: Bile leak from minor ducts still in continuity with the common bile duct, such as the cystic duct stump or small ducts in the liver bed 1
Type B: Complete occlusion of part of the biliary tree, typically an aberrant right hepatic duct that has been divided and excluded from the main biliary drainage system 1
Type C: Bile leak from a duct (often right posterior sectoral duct) that is not in communication with the main duct system 1
Type D: Lateral injury to the extrahepatic bile ducts without complete transection 1
Type E: Circumferential injury to major bile ducts, subdivided according to the Bismuth classification (E1-E5) based on the level of injury 1
Why Type B Injuries Appear Normal on ERCP
Type B injuries involve complete occlusion of an isolated segment of the biliary tree that is not in continuity with the main biliary system. When ERCP is performed:
The contrast injected during ERCP flows through the main biliary system, which appears normal 1
The occluded segment (typically an aberrant right hepatic duct) is completely separated from the main biliary tree and therefore does not fill with contrast 1
Since the occluded segment doesn't communicate with the main biliary system, its absence cannot be detected on ERCP 1
Diagnostic Challenges and Clinical Implications
The normal appearance on ERCP makes Type B injuries particularly challenging to diagnose:
Patients may present with persistent bile leak or segmental liver atrophy due to biliary obstruction despite a normal-appearing ERCP 1
Additional imaging modalities such as Magnetic Resonance Cholangiopancreatography (MRCP), Percutaneous Transhepatic Cholangiography (PTC), or CT scan may be necessary to identify the isolated occluded segment 1
The ATOM classification (Anatomic, Time Of detection, Mechanism) provides a more comprehensive assessment of such injuries by incorporating anatomical damage, vascular injury, timing of detection, and mechanism of damage 1, 2
Management Considerations
Management of Type B injuries requires specialized approaches:
Unlike Type A injuries that may be managed with endoscopic techniques, Type B injuries often require surgical intervention 1
If the occluded segment is small, conservative management may be possible as the affected liver segment may atrophy over time 1
For larger segments, surgical reconstruction with hepaticojejunostomy may be necessary to prevent progressive liver damage 3, 4
Referral to a hepatobiliary center is strongly recommended for optimal management 1, 5
Conclusion
The answer is indeed B. Type B injuries in the Strasberg-Bismuth classification will appear normal on ERCP because they involve complete occlusion of a biliary segment that is disconnected from the main biliary system, making them particularly challenging to diagnose through ERCP alone 1.