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  • • Etiologies include:

    • -Postoperative

      -Trauma

      -Chronic pancreatitis

      -Cholelithiasis or choledocholithiasis

      -Primary sclerosing cholangitis

      -Sphincter of Oddi stenosis

      -Duodenal ulcer

      -Crohn disease

      -Viral infection

      -Drug toxins

    • 80% of cases occur post-cholecystectomy

    • 10% of postoperative cases are recognized in first week, whereas 70% are recognized after 6 months

    • Chronic pancreatitis < 10% of cases (3-29% of patients with chronic pancreatitis)

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Symptoms and Signs

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  • • Fever

    • Abdominal pain

    • Jaundice

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Laboratory Findings

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  • • Hyperbilirubinemia

    • Elevated alkaline phosphatase level

    • Leukocytosis

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Imaging Findings

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  • Right upper quadrant US: Associated biloma with postoperative stricture, biliary dilatation, atrophic/calcified pancreas

    CT: Shows associated biloma with postoperative ductal injury, biliary dilatation, atrophic/calcified pancreas

    Magnetic resonance cholangiopancreatography (MRCP) or percutaneous transhepatic cholangiogram (PTC)

    • -Reveals long tapered stricture in intrapancreatic bile duct when stricture is caused by chronic pancreatitis

      -Long stricture when associated with postoperative or trauma

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  • • Recent operation

    • History of pancreatitis

    • History of choledocholithiasis

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Rule Out

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  • • Biliary, pancreatic, or ampullary malignancy

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  • • History and physical exam

    • CBC

    • Liver function tests

    • Right upper quadrant US

    • CT

    • MRCP

    • PTC

    • Endoscopic US if question of pancreatic head mass

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When to Admit

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  • • Cholangitis

    • Infected biloma or bile peritonitis

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Surgery

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Indications

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  • • Hepaticojejunostomy for most postoperative or traumatic strictures

    • Choledochoduodenostomy or choledochojejunostomy for chronic, pancreatitis-induced strictures

    • Balloon dilatation indicated for some anastomotic biliary strictures post-repair

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Contraindications

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  • • If pancreatic malignancy is suspected, pancreaticoduodenectomy should be done

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Complications

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  • • Recurrent stricture/biliary leak

    • Cholangitis

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Prognosis

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  • • Excellent in 70-90% following surgical reconstruction

    • Poor for balloon dilatation as primary therapy for strictures except as treatment for early post-repair stricture

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References

Beckingham IJ: ABC of diseases of liver, pancreas, and biliary system. Gallstone disease. BMJ 2001;322:91.  [PubMed: 11154626]

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