Editing Biliary strictures

== Workup for cholestatic pattern, with suspected stricture ==

* USS
* MRI (CT considered better by some for distal duct obstruction)
* FBE, CA19-9, CEA, IgG, IgG4, HIV
* If still no clear cause, probably going to need ERCP




== Benign biliary strictures - end result of either traumatic injury or inflammatory processes. ==

=== Iatrogenic injury (most common cause) ===

** Usually cholecystectomy - see 'cholecystectomy' page for how to avoid, and classification (Strasberg)

** Management
*** PTC and downstream dilatation
**** Use an angioplasty balloon catheter then leave a transhepatic stent
*** ERCP
*** Hepaticojejunostomy with transanastamotic stent, which stay in for 2-3 months
** Specific situations
*** Strasberg A - ERCP and biliary stent placement
*** Strasberg B or C - often do not require operative intervention, but if they get recurrent sepsis/cholangitis, a right posterior hepatic sectionectomy is typically the best option
*** Strasberg D - variable - endoscopic vs IR dilation and stenting. Primary end to end will likely fail if it's a thermal injury due to fibrosis and retraction, so excising a portion of the duct and performing hepaticojejunostomy may be necessary.
*** Strasberg E - always requires biliary-enteric reconstruction

=== PSC ===

** See separate topic

=== '''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

=== IgG4-related sclerosing cholangitis ===

** A/w AIP
** Most frequently presents as painless obstructive jaundice
** Most widely-used diagnostic criteria are HISORt

=== Ischaemic cholangiopathy ===

=== AIDS-associated cholangiopathy ===

=== Secondary sclerosing cholangitis in critically ill patients ===

=== Acute/chronic pancreatitis ===

** Pancreatic fibrosis results in distal biliary strictures involving the entire intra-pancreatic portion of CBD and causing proximal dilation
** Serum ALP is most sensitive marker
** Diagnosed on MRCP or ERCP (long, smooth, gradual tapering of distal CBD)
** Need to exclude periampullary tumour
** Treatment:
*** Most commonly biliary bypass - either choledochodeodenostomy or choledochojejunostomy
*** If malignancy can't be excluded, or chronic pain is a feature, pancreaticoduodenectomy is possible
*** Endoscopic therapy is generally not as good - can be trialled, but guidelines say if it's ineffective after 12 months, need surgery/hypass

=== Autoimmune pancreatitis ===

** Rare inflammatory disease almost uniformly responsive to steroids
** Often have obstructive jaundice and pancreatic mass
** Types
*** Type I - IgG4-related, relapsing, not limited to pancreas
*** Type II - limited to pancreas, rarely relapsing

=== Post-surgical biliary strictures ===

* Post-cholecystectomy
* Post-liver transplantation

== Malignant ==

* Pancreatic cancer
** CA19-9 is best tumour marker, but can also do CEA
* Cholangiocarcinoma




Features that support malignancy:

* Long-segment
* Irregular
* Early enhancement
* Associated soft tissue mass
* Direct invasion/infiltrative features
* DWI

[[Category:Biliary]]