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

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