Sections View Full Chapter Figures Tables Videos Annotate Full Chapter Figures Tables Videos Supplementary Content + Download Section PDF Listen ++ For further information, see CMDT Part 16-24: Biliary Stricture + Key Features Download Section PDF Listen +++ ++ 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 Download Section PDF Listen +++ ++ 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 Download Section PDF Listen +++ ++ 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 Download Section PDF Listen +++ ++ 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 a bile leak to close 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 Fully covered self-expanding metal stents and bioabsorbable stents Are alternatives to plastic stents Require fewer ERCPs to achieve stricture resolution Stent migration may occur in 10% of cases When malignancy cannot be excluded with certainty, additional endoscopic diagnostic approaches may be considered Intraductal ultrasonography Peroral cholangioscopy Confocal laser endomicroscopy Fluorescence in situ hybridization (FISH) 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