Biliary Obstruction, Benign

• • 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)

Symptoms and Signs

• • Fever

  • Abdominal pain

  • Jaundice

Laboratory Findings

• • Hyperbilirubinemia

  • Elevated alkaline phosphatase level

  • Leukocytosis

Imaging Findings

• • 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

• • Recent operation

  • History of pancreatitis

  • History of choledocholithiasis

Rule Out

• • Biliary, pancreatic, or ampullary malignancy

• • History and physical exam

  • CBC

  • Liver function tests

  • Right upper quadrant US

  • CT

  • MRCP

  • PTC

  • Endoscopic US if question of pancreatic head mass

When to Admit

• • Cholangitis

  • Infected biloma or bile peritonitis

Surgery

Indications

• • 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

Contraindications

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

Complications

• • Recurrent stricture/biliary leak

  • Cholangitis

Prognosis

• • Excellent in 70-90% following surgical reconstruction

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

References