Medscape is available in 5 Language Editions – Choose your Edition here.


Bile Duct Strictures Clinical Presentation

  • Author: William R Brugge, MD; Chief Editor: Julian Katz, MD  more...
Updated: Aug 12, 2015


In the absence of symptoms of the primary disease, most patients with bile duct strictures remain asymptomatic until the lumen of the bile duct is sufficiently narrowed to cause resistance to the flow of bile. Occasionally, patients may have intermittent episodes of right upper quadrant pain (biliary colic), with or without laboratory features of biliary obstruction. Patients most often present with features of obstructive jaundice. On occasion, a patient may present dramatically with sepsis and hypotension due to ascending cholangitis.

The clinical manifestations of obstructive jaundice may develop rapidly or slowly depending on the underlying cause. Patients may report right upper abdominal discomfort, pruritus, yellow discoloration of skin, and steatorrhea. With chronic cholestasis, xanthomas appear around the eyes, chest, back, and on extensor surfaces. Weight loss and deficiency of calcium and fat-soluble vitamins can occur. Patients also may report anorexia, nausea, vomiting, and cachexia. Insidious weight loss may suggest malignant obstruction.

Cholangitis occurs in the presence of partial or complete obstruction of the common bile duct (CBD), with increased intraluminal pressures, bacterial infection of the bile with multiplication of the organisms within the duct, and seeding of the bloodstream with bacteria or endotoxin. Cholangitis can rapidly become a life-threatening condition. Clinical presentation varies, with the Charcot triad of fever and chills, jaundice, and right upper quadrant abdominal pain occurring in most patients. A smaller proportion of those with cholangitis may also have altered mental status and hypotension (ie, Reynold pentad). In the absence of previous instrumentation, cholangitis is uncommon with malignant strictures.

The etiology of bile duct strictures is sometimes obvious at the time of presentation. In unclear cases, clues from the patient's history may help in making an accurate diagnosis. Most of the benign biliary strictures following injury during cholecystectomy go unrecognized at the time of surgery (in as many as 75% of cases). Presentation after more than 5 years may occur in 30% of cases; therefore, a history of recent or past cholecystectomy should be sought in all cases. Information about the postoperative period, especially excessive drainage from surgical wounds and drains and episodes of fever, jaundice, and abdominal distention, are important in patients presenting shortly after surgery.

A detailed history with emphasis on symptoms suggestive of pancreatitis, recurrent episodes of cholangitis, cholestatic disorders (eg, primary sclerosing cholangitis), hepatobiliary surgery,[7, 8, 9, 10, 11] trauma or radiation to the upper abdomen,[12, 13] alcohol abuse, intravenous drug use, or human immunodeficiency virus (HIV) infection[14, 15] should be obtained. This history provides valuable clues regarding the underlying disease and may prove useful in guiding management of patients with bile duct strictures.



Asymptomatic patients with bile duct strictures may have unremarkable physical examination findings. Most patients with tight strictures have clinically apparent jaundice. Excoriations of the skin may be seen in patients with pruritus.

Patients presenting with cholangitis may also have fever and right upper quadrant tenderness in addition to jaundice (ie, Charcot triad), hypotension, and altered mental status (ie, Reynold pentad).

The presence of palmar erythema, Dupuytren contracture, gynecomastia, spider angiomas, ascites, and splenomegaly may suggest underlying cirrhosis and portal hypertension. A palpable, nontender gallbladder and jaundice are usually observed in patients with malignant obstruction. The presence of these symptoms is called the Courvoisier sign. An enlarged nodular liver may indicate malignancy involving the liver or a large right upper quadrant mass may indicate a malignancy involving the gallbladder. The presence of a friction rub or bruit may also suggest malignancy.

Patients with a major surgical injury to the bile duct and those with recurrent strictures and interventions may have evidence of a bile leak in the form of a biliary fistula, biliary peritonitis, or a biloma. These complications usually become evident early in the postoperative period but sometimes appear weeks to months later.

Attention should be given to the nutritional status of the patient. Features of fat-soluble vitamin deficiency may be present and should be sought.

Contributor Information and Disclosures

William R Brugge, MD Professor of Medicine, Harvard Medical School; Director, Gastrointestinal Endoscopy Unit, Massachusetts General Hospital

William R Brugge, MD is a member of the following medical societies: American College of Gastroenterology, American College of Physicians, American Gastroenterological Association, American Pancreatic Association, American Society for Gastrointestinal Endoscopy, Crohn's and Colitis Foundation of America, American Federation for Clinical Research

Disclosure: Received grant/research funds from RedPath for consulting.


Lawrence J Cheskin, MD Director, Johns Hopkins Weight Management Center; Associate Professor, Health, Behavior & Society, Johns Hopkins Bloomberg School of Public Health; Joint Appointment, Department of Medicine, Division of Gastroenterology, Johns Hopkins University School of Medicine; International Health/Human Nutrition, JH Bloomberg School of Public Health

Lawrence J Cheskin, MD is a member of the following medical societies: American College of Gastroenterology, American College of Physicians, American Gastroenterological Association

Disclosure: Received consulting fee from Medifast for board membership; Received none from Vivus for purchase of stock as an investment; Received none from Medifast for purchase of stock as an investment.

Parviz Nikoomanesh, MD 

Parviz Nikoomanesh, MD is a member of the following medical societies: American College of Gastroenterology, American College of Physicians, American Gastroenterological Association, American Society for Gastrointestinal Endoscopy

Disclosure: Nothing to disclose.

Ashraf Saleemuddin, MD Fellow, Department of Gastroenterology, Boston University Medical Center

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

BS Anand, MD Professor, Department of Internal Medicine, Division of Gastroenterology, Baylor College of Medicine

BS Anand, MD is a member of the following medical societies: American Association for the Study of Liver Diseases, American College of Gastroenterology, American Gastroenterological Association, American Society for Gastrointestinal Endoscopy

Disclosure: Nothing to disclose.

Chief Editor

Julian Katz, MD Clinical Professor of Medicine, Drexel University College of Medicine

Julian Katz, MD is a member of the following medical societies: American College of Gastroenterology, American College of Physicians, American Gastroenterological Association, American Geriatrics Society, American Medical Association, American Society for Gastrointestinal Endoscopy, American Society of Law, Medicine & Ethics, American Trauma Society, Association of American Medical Colleges, Physicians for Social Responsibility

Disclosure: Nothing to disclose.

Additional Contributors

David Greenwald, MD Professor of Clinical Medicine, Fellowship Program Director, Department of Medicine, Division of Gastroenterology, Montefiore Medical Center, Albert Einstein College of Medicine

David Greenwald, MD is a member of the following medical societies: Alpha Omega Alpha, New York Society for Gastrointestinal Endoscopy, American College of Gastroenterology, American College of Physicians, American Gastroenterological Association, American Society for Gastrointestinal Endoscopy

Disclosure: Nothing to disclose.


Hemant Pande, MD Consulting Staff, Department of Gastroenterology, Leesville Surgical Clinic and Digestive Disease Center

Hemant Pande, MD is a member of the following medical societies: American College of Gastroenterology, American Gastroenterological Association, and American Society for Gastrointestinal Endoscopy

Disclosure: Nothing to disclose.

  1. Vecchio R, Ferrara M, Pucci L, Meli G, Latteri S. [Treatment of iatrogenic lesions of the common bile duct] [Italian]. Minerva Chir. 1995 Jan-Feb. 50(1-2):29-38. [Medline].

  2. Hanau LH, Steigbigel NH. Acute (ascending) cholangitis. Infect Dis Clin North Am. 2000 Sep. 14(3):521-46. [Medline].

  3. Hastier P, Buckley JM, Peten EP, Dumas R, Delmont J. Long term treatment of biliary stricture due to chronic pancreatitis with a metallic stent. Am J Gastroenterol. 1999 Jul. 94(7):1947-8. [Medline].

  4. Deviere J, Cremer M, Baize M, Love J, Sugai B, Vandermeeren A. Management of common bile duct stricture caused by chronic pancreatitis with metal mesh self expandable stents. Gut. 1994 Jan. 35(1):122-6. [Medline]. [Full Text].

  5. Kamisawa T, Tu Y, Egawa N, et al. Involvement of pancreatic and bile ducts in autoimmune pancreatitis. World J Gastroenterol. 2006 Jan 28. 12(4):612-4. [Medline]. [Full Text].

  6. Magistrelli P, Masetti R, Coppola R, et al. Changing attitudes in the palliation of proximal malignant biliary obstruction. J Surg Oncol Suppl. 1993. 3:151-3. [Medline].

  7. Klein AS, Savader S, Burdick JF, et al. Reduction of morbidity and mortality from biliary complications after liver transplantation. Hepatology. 1991 Nov. 14(5):818-23. [Medline].

  8. Orons PD, Sheng R, Zajko AB. Hepatic artery stenosis in liver transplant recipients: prevalence and cholangiographic appearance of associated biliary complications. AJR Am J Roentgenol. 1995 Nov. 165(5):1145-9. [Medline]. [Full Text].

  9. Mosca S, Militerno G, Guardascione MA, et al. Late biliary tract complications after orthotopic liver transplantation: diagnostic and therapeutic role of endoscopic retrograde cholangiopancreatography. J Gastroenterol Hepatol. 2000 Jun. 15(6):654-60. [Medline].

  10. Pozsar J, Sahin P, Laszlo F, Topa L. Endoscopic treatment of sphincterotomy-associated distal common bile duct strictures by using sequential insertion of multiple plastic stents. Gastrointest Endosc. 2005 Jul. 62(1):85-91. [Medline].

  11. Schwartz DA, Petersen BT, Poterucha JJ, Gostout CJ. Endoscopic therapy of anastomotic bile duct strictures occurring after liver transplantation. Gastrointest Endosc. 2000 Feb. 51(2):169-74. [Medline].

  12. Cherqui D, Palazzo L, Piedbois P, et al. Common bile duct stricture as a late complication of upper abdominal radiotherapy. J Hepatol. 1994 Jun. 20(6):693-7. [Medline].

  13. Nakakubo Y, Kondo S, Katoh H, Shimizu M. Biliary stricture as a possible late complication of radiation therapy. Hepatogastroenterology. 2000 Nov-Dec. 47(36):1531-2. [Medline].

  14. Cello JP. Human immunodeficiency virus-associated biliary tract disease. Semin Liver Dis. 1992 May. 12(2):213-8. [Medline].

  15. Nash JA, Cohen SA. Gallbladder and biliary tract disease in AIDS. Gastroenterol Clin North Am. 1997 Jun. 26(2):323-35. [Medline].

  16. Colonna JO 2nd, Shaked A, Gomes AS, et al. Biliary strictures complicating liver transplantation. Incidence, pathogenesis, management, and outcome. Ann Surg. 1992 Sep. 216(3):344-50; discussion 350-2. [Medline]. [Full Text].

  17. Sundaram V, Jones DT, Shah NH, et al. Posttransplant biliary complications in the pre- and post-model for end-stage liver disease era. Liver Transpl. 2011 Apr. 17(4):428-35. [Medline].

  18. Fan ST, Ng IO, Choi TK, Lai EC. Tuberculosis of the bile duct: a rare cause of biliary stricture. Am J Gastroenterol. 1989 Apr. 84(4):413-4. [Medline].

  19. Patel AH, Harnois DM, Klee GG, LaRusso NF, Gores GJ. The utility of CA 19-9 in the diagnoses of cholangiocarcinoma in patients without primary sclerosing cholangitis. Am J Gastroenterol. 2000 Jan. 95(1):204-7. [Medline].

  20. Lempinen M, Isoniemi H, Makisalo H, et al. Enhanced detection of cholangiocarcinoma with serum trypsinogen-2 in patients with severe bile duct strictures. J Hepatol. 2007 Nov. 47(5):677-83. [Medline].

  21. Stavropoulos S, Larghi A, Verna E, Battezzati P, Stevens P. Intraductal ultrasound for the evaluation of patients with biliary strictures and no abdominal mass on computed tomography. Endoscopy. 2005 Aug. 37(8):715-21. [Medline].

  22. Nandalur KR, Hussain HK, Weadock WJ, et al. Possible biliary disease: diagnostic performance of high-spatial-resolution isotropic 3D T2-weighted MRCP. Radiology. 2008 Dec. 249(3):883-90. [Medline].

  23. Mansfield JC, Griffin SM, Wadehra V, Matthewson K. A prospective evaluation of cytology from biliary strictures. Gut. 1997 May. 40(5):671-7. [Medline]. [Full Text].

  24. Kipp BR, Stadheim LM, Halling SA, et al. A comparison of routine cytology and fluorescence in situ hybridization for the detection of malignant bile duct strictures. Am J Gastroenterol. 2004 Sep. 99(9):1675-81. [Medline].

  25. Gong Y, Huang ZB, Christensen E, Gluud C. Ursodeoxycholic acid for primary biliary cirrhosis. Cochrane Database Syst Rev. 2008 Jul 16. CD000551. [Medline]. [Full Text].

  26. Mahid SS, Jafri NS, Brangers BC, et al. Meta-analysis of cholecystectomy in symptomatic patients with positive hepatobiliary iminodiacetic acid scan results without gallstones. Arch Surg. 2009 Feb. 144(2):180-7. [Medline].

  27. Olsen JC, McGrath NA, Schwarz DG, Cutcliffe BJ, Stern JL. A double-blind randomized clinical trial evaluating the analgesic efficacy of ketorolac versus butorphanol for patients with suspected biliary colic in the emergency department. Acad Emerg Med. 2008 Aug. 15(8):718-22. [Medline].

  28. Bismuth H, Nakache R, Diamond T. Management strategies in resection for hilar cholangiocarcinoma. Ann Surg. 1992 Jan. 215(1):31-8. [Medline]. [Full Text].

  29. Bjornsson E, Lindqvist-Ottosson J, Asztely M, Olsson R. Dominant strictures in patients with primary sclerosing cholangitis. Am J Gastroenterol. 2004 Mar. 99(3):502-8. [Medline].

  30. Yoon WJ, Brugge WR. Endoscopic evaluation of bile duct strictures. Gastrointest Endosc Clin N Am. 2013 Apr. 23(2):277-93. [Medline].

  31. Bueno JT, Gerdes H, Kurtz RC. Endoscopic management of occluded biliary Wallstents: a cancer center experience. Gastrointest Endosc. 2003 Dec. 58(6):879-84. [Medline].

  32. Frattaroli FM, Reggio D, Guadalaxara A, Illomei G, Pappalardo G. Benign biliary strictures: a review of 21 years of experience. J Am Coll Surg. 1996 Nov. 183(5):506-13. [Medline].

  33. Gibbons JC, Williams SJ. Progress in the endoscopic management of benign biliary strictures. J Gastroenterol Hepatol. 1998 Feb. 13(2):116-24. [Medline].

  34. Ishizuka D, Shirai Y, Hatakeyama K. Ischemic biliary stricture due to lymph node dissection in the hepatoduodenal ligament. Hepatogastroenterology. 1998 Nov-Dec. 45(24):2048-50. [Medline].

  35. Itani KM, Taylor TV. The challenge of therapy for pancreatitis-related common bile duct stricture. Am J Surg. 1995 Dec. 170(6):543-6. [Medline].

  36. Kadir S, White RI Jr. Biliary stricture dilatation: multicenter review of clinical management in 73 patients. Radiology. 1987 Jan. 162(1 pt 1):286. [Medline]. [Full Text].

  37. Kim KH, Sung CK, Park BG, et al. Clinical significance of intrahepatic biliary stricture in efficacy of hepatic resection for intrahepatic stones. J Hepatobiliary Pancreat Surg. 1998. 5(3):303-8. [Medline].

  38. Levy MJ, Baron TH, Clayton AC, et al. Prospective evaluation of advanced molecular markers and imaging techniques in patients with indeterminate bile duct strictures. Am J Gastroenterol. 2008 May. 103(5):1263-73. [Medline].

  39. Lipsett PA, Pitt HA, Colombani PM, Boitnott JK, Cameron JL. Choledochal cyst disease. A changing pattern of presentation. Ann Surg. 1994 Nov. 220(5):644-52. [Medline]. [Full Text].

  40. Lombard M, Farrant M, Karani J, Westaby D, Williams R. Improving biliary-enteric drainage in primary sclerosing cholangitis: experience with endoscopic methods. Gut. 1991 Nov. 32(11):1364-8. [Medline]. [Full Text].

  41. Maier M, Kohler B, Benz C, Korber H, Riemann JF. [Percutaneous transhepatic cholangioscopy (PTCS)--an important supplement in diagnosis and therapy of biliary tract diseases (indications, technique and results)] [German]. Z Gastroenterol. 1995 Aug. 33(8):435-9. [Medline].

  42. McDonald ML, Farnell MB, Nagorney DM, Ilstrup DM, Kutch JM. Benign biliary strictures: repair and outcome with a contemporary approach. Surgery. 1995 Oct. 118(4):582-90; discussion 590-1. [Medline].

  43. Mendler MH, Bouillet P, Sautereau D, et al. Value of MR cholangiography in the diagnosis of obstructive diseases of the biliary tree: a study of 58 cases. Am J Gastroenterol. 1998 Dec. 93(12):2482-90. [Medline].

  44. Moore AV Jr, Illescas FF, Mills SR, et al. Percutaneous dilation of benign biliary strictures. Radiology. 1987 Jun. 163(3):625-8. [Medline]. [Full Text].

  45. Morrison MC, Lee MJ, Saini S, Brink JA, Mueller PR. Percutaneous balloon dilatation of benign biliary strictures. Radiol Clin North Am. 1990 Nov. 28(6):1191-201. [Medline].

  46. Nealon WH, Urrutia F. Long-term follow-up after bilioenteric anastomosis for benign bile duct stricture. Ann Surg. 1996 Jun. 223(6):639-45; discussion 645-8. [Medline]. [Full Text].

  47. Pereira-Lima JC, Jakobs R, Maier M, et al. Endoscopic biliary stenting for the palliation of pancreatic cancer: results, survival predictive factors, and comparison of 10-French with 11.5-French gauge stents. Am J Gastroenterol. 1996 Oct. 91(10):2179-84. [Medline].

  48. Rosch T, Hofrichter K, Frimberger E, et al. ERCP or EUS for tissue diagnosis of biliary strictures? A prospective comparative study. Gastrointest Endosc. 2004 Sep. 60(3):390-6. [Medline].

  49. Roslyn JJ, Binns GS, Hughes EF. Open cholecystectomy. A contemporary analysis of 42,474 patients. Ann Surg. 1993 Aug. 218(2):129-37. [Medline].

  50. Shah RJ, Langer DA, Antillon MR, Chen YK. Cholangioscopy and cholangioscopic forceps biopsy in patients with indeterminate pancreaticobiliary pathology. Clin Gastroenterol Hepatol. 2006 Feb. 4(2):219-25. [Medline].

  51. Smits ME, Rauws EA, van Gulik TM, et al. Long-term results of endoscopic stenting and surgical drainage for biliary stricture due to chronic pancreatitis. Br J Surg. 1996 Jun. 83(6):764-8. [Medline].

  52. Tenner S, Roston A, Lichtenstein D, et al. Eosinophilic cholangiopathy. Gastrointest Endosc. 1997 Mar. 45(3):307-9. [Medline].

  53. Tocchi A, Mazzoni G, Liotta G, et al. Management of benign biliary strictures: biliary enteric anastomosis vs endoscopic stenting. Arch Surg. 2000 Feb. 135(2):153-7. [Medline]. [Full Text].

  54. Vitale GC, George M, McIntyre K. Endoscopic management of benign and malignant biliary strictures. Am J Surg. 1996 Jun. 171(6):553-7. [Medline].

  55. Vitale GC, Larson GM, George M, Tatum C. Management of malignant biliary stricture with self-expanding metallic stent. Surg Endosc. 1996 Oct. 10(10):970-3. [Medline].

Endoscopic retrograde cholangiopancreatographic image of a cholangiocarcinoma at the bifurcation of the right and left hepatic ducts (Klatskin tumor).
Endoscopic retrograde cholangiopancreatographic cholangiogram demonstrating a long bile duct stricture that represents external compression by gallbladder cancer.
Transhepatic cholangiogram with an external drainage catheter in place.
Endoscopic retrograde cholangiopancreatographic image of a cholangiogram in a patient with cholangiocarcinoma whose condition has been treated with a metal stent.
Endoscopic retrograde cholangiopancreatographic cholangiogram of a solitary benign stricture of the distal bile duct. Resection demonstrated sclerosing cholangitis.
Endoscopic retrograde cholangiopancreatographic cholangiogram demonstrating an isolated mid-hepatic duct stricture as a result of pancreatic cancer.
Endoscopic retrograde cholangiopancreatographic cholangiogram demonstrating diffuse stricturing of the intrahepatic ducts that is consistent with primary sclerosing cholangitis.
Periductal onion skin fibrosis seen in primary sclerosing cholangitis.
Periductal lymphocytic and plasma cell infiltrate that is consistent with autoimmune cholangiopathy.
Focal intrahepatic benign bile duct stricture after cholecystectomy.
Multiple small bile duct stones seen on magnetic resonance cholangiopancreatography (MRCP).
Irregular common bile duct stricture as a result of cholangiocarcinoma.
This image is an example of an intraoperative cholangiogram performed during a laparoscopic cholecystectomy.
Focal bile duct stricture as a result of pancreatic cancer in the head of the pancreas.
Percutaneous transhepatic cholangiogram with balloon dilation of a postoperative bile duct stricture.
Benign distal common bile duct stricture seen during a cholecystostomy injection in an elderly male. The stricture resolved with a 4-week course of oral corticosteroid therapy.
All material on this website is protected by copyright, Copyright © 1994-2016 by WebMD LLC. This website also contains material copyrighted by 3rd parties.