Editing Biliary strictures (section)

=== '''Recurrent pyogenic cholangitis''' ===

** A syndrome of repeated attacks of cholangitis secondary to biliary stones and strictures that involve the extra- and intra-hepatic ducts
*** Also known as oriental cholangiohepatitis or hepatolithiasis
** Epidemiology
*** Almost exclusively seen in Asians (in Asia and diaspora)
*** Men and women equal
*** Most commonly strikes at 20-40yo in lower SES
** Aetiology
*** Unknown
** Pathophysiology
*** Stones and strictures develop in the biliary tree, but not known which occurs first
*** Stones are bilirubinate stones
*** Association with Clonorchis sinensis and Ascaris lumbricoides
*** Strictures usually involve the intrahepatic main hepatic ducts, most often the left hepatic duct
*** GB can be involved (20%)
** Complications
*** Cirrhosis can develop secondary to strictures
*** Choledochoduodenal fistula
*** Acute pancreatitis
*** Increased incidence of cholangiocarcinoma
** Presentation
*** Repeated bouts of cholangitis
** Diagnosis
*** Favoured if there are multiple ductal stones, abscesses
*** Use combination of USS, CT and ERCP
** Treatment
*** Acute

**** Focus on decompression
**** Surgical has historically been favoured - open CBD exploration or endoscopic papillotomy with stenting
**** PTC reserved for poor-risk surgical patients

*** Chronic

**** Surgery is often indicated
**** Hepatic resection if it's within an isolated segment (for intra-hepatic strictures, hepatic atrophy, liver abscess, or suspicion of cholangiocarcinoma)
**** All the way through to liver transplant