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Key Features

  • Results from surgical anastomosis or injury in ~95% of cases

  • Cholangitis is most common complication

  • Secondary biliary cirrhosis is inevitable if stricture is not treated

Clinical Findings

  • Ductal injury may not be recognized in the immediate postoperative period

  • With complete occlusion, jaundice develops rapidly

  • More often, a tear is accidentally made in the duct, with excessive or prolonged bile loss from the surgical drains as the earliest manifestation

  • Typically, episodes of pain, fever, chills, and jaundice occur within a few weeks to months after cholecystectomy

  • Right upper quadrant (RUQ) abdominal tenderness

  • During an acute attack of cholangitis, there may be

    • Fever

    • Jaundice

    • RUQ abdominal tenderness

Diagnosis

  • Serum alkaline phosphatase is usually elevated

  • Hyperbilirubinemia is variable, fluctuating in the range of 5–10 mg/dL (85.5–171 mcmol/L) during exacerbations

  • Blood cultures may be positive during acute cholangitis

  • Magnetic resonance cholangiography or multidetector CT can demonstrate stricture and outline the anatomy

Treatment

  • Endoscopic retrograde cholangiopancreatography (ERCP)

    • First-line interventional approach

    • Permits biopsy and cytologic specimens to exclude bile duct malignancy

  • Endoscopic ultrasound-guided fine-needle aspiration is an even more sensitive test for distal bile duct malignancy

  • Sphincterotomy allows closure of a bile leak and dilation (often repeated) and stent placement for a stricture, thereby avoiding surgical repair in some cases

  • When ERCP is unsuccessful, dilation may be accomplished by percutaneous transhepatic cholangiography (PTC) or under endoscopic ultrasonographic guidance

  • Placement of multiple plastic stents appears to be more effective than placement of a single stent

  • Covered metal stents and bioabsorbable stents

    • Are alternatives to plastic stents

    • Require fewer ERCPs to achieve stricture resolution

  • Malignancy may be excluded by

    • Endoscopic ultrasonography

    • Intraductal ultrasonography

    • Cholangioscopy

  • Surgical exploration may be needed to exclude cholangiocarcinoma

  • Operative treatment frequently necessitates performance of an end-to-end ductal repair, choledochojejunostomy, or hepaticojejunostomy to reestablish bile flow into the intestine

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