Biliary Stricture

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 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

• Covered metal stents and bioabsorbable stents

  • Are alternatives to plastic stents

  • Require fewer ERCPs to achieve stricture resolution

• When malignancy cannot be excluded with certainty, additional diagnostic approaches may be considered

  • Intraductal ultrasonography

  • Peroral cholangioscopy

  • Confocal laser endomicroscopy

  • Optical coherence tomography

  • Fluorescence in situ hybridization (FISH)

  • Next-generation genetic sequencing

• 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