Biliary Stricture

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

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

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

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