Stelzl A, El-Mahrouk M, Stiegler P, Wagner M, Sucher R. Biliary sunrise - bile color as visible sign for hepatic ischemia after iatrogenic partial liver de-arterialization: A case report. World J Gastroenterol 2026; 32(31): 122449 [DOI: 10.3748/wjg.122449]
Corresponding Author of This Article
Mohamed El-Mahrouk, MD, Division of General, Visceral and Transplantation Surgery, Department of Surgery, Medical University of Graz, Auenbruggerplatz 29, Graz 8036, Steiermark, Austria. mohamed.el-mahrouk@medunigraz.at
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Gastroenterology & Hepatology
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case-report
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Stelzl A, El-Mahrouk M, Stiegler P, Wagner M, Sucher R. Biliary sunrise - bile color as visible sign for hepatic ischemia after iatrogenic partial liver de-arterialization: A case report. World J Gastroenterol 2026; 32(31): 122449 [DOI: 10.3748/wjg.122449]
World J Gastroenterol. Aug 21, 2026; 32(31): 122449 Published online Aug 21, 2026. doi: 10.3748/wjg.122449
Biliary sunrise - bile color as visible sign for hepatic ischemia after iatrogenic partial liver de-arterialization: A case report
Adrian Stelzl, Mohamed El-Mahrouk, Philipp Stiegler, Martin Wagner, Robert Sucher
Adrian Stelzl, Mohamed El-Mahrouk, Philipp Stiegler, Robert Sucher, Division of General, Visceral and Transplantation Surgery, Department of Surgery, Medical University of Graz, Graz 8036, Steiermark, Austria
Martin Wagner, Department of Internal Medicine, Medical University of Graz, Graz 8010, Steiermark, Austria
Author contributions: Stelzl A and El-Mahrouk M drafted the manuscript; Stiegler P, Wagner M, and Sucher R critically revised the manuscript for important intellectual content; and all authors read and approved the final version of the manuscript.
AI contribution statement: AI tools were used solely for literature research and formatting assistance. No AI tool was involved in the generation of research data, interpretation of results, or formulation of conclusions. All AI-generated outputs were critically reviewed and revised by the authors.
Informed consent statement: All procedures were conducted in accordance with institutional and international ethical standards. Due to the patient’s death, informed consent for publication could not be obtained; however, no identifiable personal information is included, and full anonymization has been ensured. The Medical University of Graz permits publication of fully anonymized data retrieved for clinical purposes.
Conflict-of-interest statement: All the authors report no relevant conflicts of interest for this article.
CARE Checklist (2016) statement: The authors have read the CARE Checklist (2016), and the manuscript was prepared and revised according to the CARE Checklist (2016).
Corresponding author: Mohamed El-Mahrouk, MD, Division of General, Visceral and Transplantation Surgery, Department of Surgery, Medical University of Graz, Auenbruggerplatz 29, Graz 8036, Steiermark, Austria. mohamed.el-mahrouk@medunigraz.at
Received: April 21, 2026 Revised: May 12, 2026 Accepted: June 23, 2026 Published online: August 21, 2026 Processing time: 106 Days and 0.8 Hours
Abstract
BACKGROUND
Bile duct injuries (BDI) present a serious complication of laparoscopic cholecystectomy. Additional arterial injuries, usually affecting the right hepatic artery (RHA), significantly worsen the prognosis. The combination of BDI and RHA injury is rare, but its occurrence is associated with a high risk of hepatic ischemia and necrosis.
CASE SUMMARY
A 72-year-old multimorbid patient was transferred to our tertiary center after laparoscopic cholecystectomy with combined complete transection of the common hepatic duct (Strasberg E4) and the RHA. Imaging showed delayed arterial contrast enhancement of the right hepatic lobe and biliary obstruction. During surgical revision, the right and left biliary systems were repaired with a combined hepaticojejunostomy and Roux-en-Y reconstruction. Three internal-external biliary Neuhaus drains were inserted into the right posterolateral, right anteromedial, and left bile ducts to splint the anastomosis. Postoperatively, there was a rapid decrease in serum bilirubin levels with no evidence of biliary leakage. A noticeable difference in the color of the drained bile between the individual liver areas was observed, correlating with the extent of regional liver ischemia. This characteristic pattern was referred to as “biliary sunrise”. Despite an initially stable course, the patient died as a result of septic multiple organ failure.
CONCLUSION
This case illustrates the pathophysiological consequences of a combined BDI and RHA injury. Segmental differences in biliary pigmentation can serve as a macroscopic indication of the extent of hepatic ischemia.
Core Tip: Hepatic ischemia occurs after hepatic arterial occlusion with concomitant injury to collaterals, most importantly the peribiliary vascular plexus. This case of combined bile duct and right hepatic artery injury demonstrates that regional differences in bile color correlate with the extent of segmental hepatic ischemia. Darker, more concentrated bile originated from more ischemic areas, whereas lighter bile indicated preserved perfusion. Changes in bile color, although not studied extensively in recent years, might reflect underlying alterations in bile composition. These macroscopic changes provide a simple, real-time indicator of hepatobiliary functional impairment and offer interesting insights into the pathophysiology of ischemic cholestasis.
