TUCSON, ARIZ. — Bile leaks most often accompany blunt liver injury in patients with the most severe liver trauma and in those who need angiographic embolization, reported Wendy L. Wahl, M.D., at the annual meeting of the Central Surgical Association.
In a review of 281 adults with blunt liver injury during 1997–2004, Dr. Wahl and her associates at the University of Michigan, Ann Arbor, determined that bile leaks usually stem from high-grade liver injuries in patients initially assigned to receive angiographic embolization. They found that hepatobiliary iminodiacetic acid (HIDA) scanning, or cholescintigraphy, is often the optimal method to diagnose bile leaks after nonoperative management.
The investigators divided the patients into three groups:
▸ An observation group of patients for whom there was no intention to operate or use angiographic embolization at admission.
▸ An operative group of patients who immediately went to the operating room from the emergency department or CT scanner. They included patients who first went to the operating room and then received angiographic embolization.
▸ An arteriography group of patients who received an angiogram, with or without embolization
Operative and arteriographic patients had significantly higher liver Abbreviated Injury Scale (AIS) scores than did observed patients (3.2 and 4 vs. 2.4, respectively).
The need for arteriography was an independent risk factor for the development of a bile leak, even if a patient was sent to get angiographic embolization but did not actually receive it, said Dr. Wahl, director of the trauma-burn ICU at the university. Patients in the arteriographic group had a significantly higher rate of bile leak (43%) than did patients in the operative (19%) or observation groups (2%).
Liver AIS scores were significantly higher in patients who developed bile leaks (4.2) than in those who did not (2.6). In fact, all bile leaks occurred in the 57 patients who had high-grade liver injuries (grade 4 or higher).
Clinicians detected most of the bile leaks with HIDA scans, but they detected some during laparotomy, laparoscopy, endoscopic retrograde cholangiopancreatography, or percutaneous transhepatic cholangiography. “If the patient had a negative HIDA scan, we did not find that the patients developed a bile leak after their initially negative HIDA scan,” she said.
On average, patients who received treatment for a bile leak by day 4 had a significantly shorter hospital stay than those treated after that (16 vs. 32 days). Each additional day of a delayed bile leak diagnosis after day 4 added 3.3 days to the length of stay.
Dr. Wahl's group now follows a guideline of doing a HIDA scan on day 2 or 3 in patients who have had a high-grade liver injury, an angiographic embolization, or just an angiogram for their liver-related injuries.