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For further information, see CMDT Part 18-24: Biliary Stricture
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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
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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
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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
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Endoscopic retrograde cholangiopancreatography (ERCP)
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
When malignancy cannot be excluded with certainty, additional diagnostic approaches may be considered
Intraductal ultrasonography
Direct peroral cholangioscopy
Narrow-band imaging
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