Bile Duct Strictures Clinical Presentation

  • Author: William R Brugge, MD; Chief Editor: Julian Katz, MD   more...
 
Updated: May 6, 2011
 

History

  • In the absence of symptoms of the primary disease, most patients with bile duct strictures (biliary 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 (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 (biliary strictures).
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Physical

  • Asymptomatic patients with bile duct strictures (biliary 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.
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Causes

Bile duct strictures (biliary strictures) can be benign or malignant, described as follows:

  • Benign bile duct strictures (biliary strictures)
    • Postoperative injury after cholecystectomy: Approximately 80% of benign strictures occur following injury during a cholecystectomy. Injury to bile ducts can occur during either laparoscopic or open cholecystectomy. Most strictures after a laparoscopic procedure are short and occur more commonly in the common hepatic duct, distal to the confluence of the right and left hepatic ducts.
    • After open cholecystectomy, strictures are more common in the CBD. This phenomenon is likely due to the ease with which this area may be accessed by the laparoscope. Most iatrogenic injuries go unrecognized at the time of operation. Because of sepsis or peritonitis, the clinical status of the patient with an unrecognized biliary tract injury can deteriorate rapidly, thus early diagnosis is imperative.
    • The causes of benign bile duct strictures (biliary strictures) are usually surgical inexperience, failure to recognize abnormal biliary anatomy and congenital anomalies, acute inflammation, misplacement of clips, excessive use of cautery, and excessive dissection around the major bile ducts, resulting in ischemic injury. However, a significant proportion of strictures occur during operations described as simple and uneventful. Bile duct strictures (biliary strictures) can also occur as unexpected complications after other surgeries, such as gastrectomy, pancreatic surgery, or hepatic and portal vein surgery.
    • Pancreatitis: Jaundice due to obstruction of the intrapancreatic segment of the CBD occurs in patients with chronic pancreatitis and accounts for approximately 10% of the benign strictures. Acute pancreatitis, pseudocyst, and pancreatic abscess are also uncommonly associated with the development of bile duct strictures (biliary strictures).
    • PSC: PSC is a disease that causes strictures, beading, and irregularities of the intrahepatic and extrahepatic bile ducts. Approximately 70% of PSC cases are associated with inflammatory bowel disease. The extent and distribution of bile duct involvement is variable.
    • HIV cholangiopathy: Patients with HIV cholangiopathy usually have advanced acquired immunodeficiency syndrome (AIDS) with CD4 lymphocyte counts less than 100/mm3 and poor long-term survival prognoses. Cryptosporidium and cytomegalovirus may be responsible for more than 90% of cases. Other causes of HIV cholangiopathy, occurring in fewer than 10% of patients, include microsporidia Mycobacterium avium-intracellulare (MAI), Cyclospora, Isospora, and Cryptococcus. Most patients present with severe right upper quadrant pain, nausea, vomiting, and fever.
    • Orthotopic liver transplantation (OLT)[7, 8, 9, 11, 16] : Bile duct strictures (biliary strictures) usually occur 2-6 months after OLT. Anastomotic strictures are more common, with choledochocholedochostomy site strictures more common than choledochojejunostomy site strictures. Hepatic artery ischemia after OLT also can present as an anastomotic stricture, a hilar stricture, or diffuse stricturing of the biliary tree. Other causes of strictures after OLT are ABO incompatibility, ischemia-reperfusion injury, and chronic allograft rejection.
    • A study by Sundaram et al investigated the relationship between biliary strictures and transplantation in the era of the Model for End-Stage Liver Disease (MELD).[17] The study concluded that even when using multivariate analysis to allow for other risk factors, transplantation in the post-MELD era is an independent predictor for stricture development. Further studies are needed to determine the etiology of this increase.
    • Mirizzi syndrome: This condition is observed in 1% of patients with cholecystectomies. Extrinsic compression of the common hepatic duct due to a gallstone impacted in the Hartmann pouch or cystic duct results in jaundice and cholangitis. Repeated episodes of inflammation can lead to formation of a stricture (type I) or pressure necrosis leading to the formation of a cholecystocholedochal fistula (type II).
    • Radiation[12, 13] : Bile duct strictures (biliary strictures) can occur as a late complication of radiation therapy in the upper abdomen for cancer or lymphoma, sometimes presenting many years after treatment.
    • Blunt abdominal trauma: This can lead to bile duct strictures, which usually have a delayed presentation.
    • Polyarteritis nodosa and systemic lupus erythematosus (SLE): These are autoimmune diseases involving small- to medium-sized arteries. They can present (rarely) as extrahepatic biliary obstruction secondary to biliary strictures.
    • Tuberculosis[18] and histoplasmosis: These conditions have rarely been reported to cause bile duct strictures (biliary strictures) in individuals who are immunocompetent.
    • Chemotherapeutic drugs: Hepatic artery infusion of 5-fluorodeoxyuridine (FdUrd, FUDR) or other chemotherapeutic drugs may cause bile duct strictures (biliary stricture).
    • Sphincter of Oddi dysfunction or papillary stenosis: Patients usually present with biliary colic after cholecystectomy. The anomaly is in the smooth muscle surrounding the terminal portion of the CBD, with an abnormal basal sphincter pressure of greater than 40 mm Hg.
    • Choledochal cysts: Choledochal cysts are uncommon anomalies of the biliary system manifested by cystic dilatation of the extrahepatic biliary tree, intrahepatic biliary tree, or both. This condition is found most frequently in Asian persons and in females. Associated hepatobiliary complications include recurrent cholangitis, bile duct stricture (biliary stricture), cholelithiasis, choledocholithiasis, and recurrent acute pancreatitis.
    • Recurrent pyogenic cholangitis: This condition (previously known as Oriental cholangiohepatitis) and hepatolithiasis are prevalent in Southeast Asia and present a difficult management problem. Recurrent pyogenic cholangitis is characterized by recurrent attacks of suppurative cholangitis with strictures and dilatation of bile ducts and numerous pigment stones in the intrahepatic and extrahepatic bile ducts. It is thought to be precipitated by an infestation of liver flukes and round worms. In the United States, this disease is observed mostly in Asian immigrants.
    • Inflammatory strictures: In addition to pancreatitis, choledocholithiasis can also cause chronic inflammation and fibrosis, leading to strictures of the CBD and sphincter of Oddi.
    • Endoscope-related strictures: Postendoscopic sphincterotomy stricture is possible.
    • Idiopathic: A few cases of idiopathic benign bile duct strictures (biliary strictures) have been reported.
    • Miscellaneous: Strictures have been described in association with duodenal diverticulum, Crohn disease, hepatic artery aneurysm, cystic fibrosis with liver involvement, eosinophilic cholecystitis, and cholangitis.
  • Malignant causes of bile duct strictures (biliary strictures)
    • Pancreatic cancer: In the United States, adenocarcinoma of the pancreas is the most common cause of malignant biliary obstruction. Pancreatic cancer accounts for nearly 33,000 cases of cancer each year and has become the fifth leading cause of cancer mortality. Pancreatic cancer usually presents in the sixth and subsequent decades of life.
    • Mucinous cystadenocarcinoma: This pancreatic tumor may invade the bile duct and cause obstruction, which characteristically results in extrusion of mucin from the lumen.
    • Ampullary carcinoma: Adenocarcinoma of the ampulla of Vater usually arises from a benign adenoma. This condition is less common than pancreatic cancer, but symptoms of obstructive jaundice (80%) or pancreatitis are observed relatively early in its course. Both benign and malignant ampullary tumors can occur sporadically, or in the setting of genetic syndromes. The incidence of ampullary tumors is increased 200-300 fold in any patients with hereditary polyposis syndromes, such as familial adenomatous polyposis (FAP) and hereditary nonpolyposis colorectal cancer (HNPCC).
    • Gallbladder carcinoma: Extension of the cancer beyond the gallbladder can cause long bile duct strictures (biliary strictures) and obstruction, and it is a poor prognostic sign. In the United States, gallbladder cancer is the fifth most common gastrointestinal malignancy, with 6000 new cases each year. Gallbladder cancer occurs at a higher frequency in Native Americans and in people from Asia, Africa, and Latin America.
    • Cholangiocarcinoma: This cancer arises from the biliary epithelium and is usually seen in association with choledochal cysts, PSC, chronic ulcerative colitis, and infestation by liver flukes. Obstructive jaundice is the major clinical manifestation of cholangiocarcinoma. Cholangiocarcinoma is more common in the upper portions of the biliary tree (hilar or Klatskin tumor) than in the lower portions of the biliary tree (distal bile duct cancer), but it can also be diffuse in 10% of cases (see image below). Endoscopic retrograde cholangiopancreatographic imEndoscopic retrograde cholangiopancreatographic image of a cholangiocarcinoma at the bifurcation of the right and left hepatic ducts (Klatskin tumor).
    • For unclear reasons, the incidence of intrahepatic cholangiocarcinoma has been rising over the past 2 decades in Europe, North America, Asia, Japan, and Australia, whereas rates of extrahepatic cholangiocarcinoma are declining internationally.
    • Hepatocellular cancer: This is the most common primary liver malignancy. Hepatocellular cancer is the fourth leading cause of cancer-related death in the world and the third most common among men. Hepatocellular cancer is more common in the Far East than in the United States and is usually associated with cirrhosis resulting from hepatitis B or hepatitis C. The condition can present (rarely) with features of invasion of the extrahepatic biliary system as the predominant clinical manifestation.
    • Lymphoma and metastatic cancers to the liver and nodes in the porta hepatis: These cancers can sometimes be the cause of malignant bile duct strictures (biliary strictures). Colorectal carcinoma, adenocarcinoma of the lung, pancreatic carcinoma, and renal cell carcinoma are the common tumors that metastasize to the liver. Metastatic porta lymphadenopathy may cause high-grade obstruction of the common hepatic duct.
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Contributor Information and Disclosures
Author

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 Federation for Clinical Research, American Gastroenterological Association, American Pancreatic Association, American Society of Gastrointestinal Endoscopy, and Crohns and Colitis Foundation of America

Disclosure: Nothing to disclose.

Coauthor(s)

Ashraf Saleemuddin, MD  Staff Physician, Department of Internal Medicine, Boston University Medical Center

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.

Parviz Nikoomanesh, MD  Clinical Director of Gastroenterology, Director of Endoscopy, Associate Professor, Department of Internal Medicine, Bayview Medical Center, Johns Hopkins University School of Medicine

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

Disclosure: Nothing to disclose.

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, and American Gastroenterological Association

Disclosure: Medifast Salary Employment; Mushroom Council Grant/research funds research grant; Medifast Ownership interest consulting; Chair, Advisory Bd; Vivus Honoraria Speaking and teaching; Vivus Consulting fee Board membership; Vivus stock ownership None

Specialty Editor Board

David Greenwald, MD  Associate 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, American College of Gastroenterology, American College of Physicians, American Gastroenterological Association, American Society for Gastrointestinal Endoscopy, and New York Society for Gastrointestinal Endoscopy

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Senior Pharmacy Editor, eMedicine

Disclosure: eMedicine Salary Employment

James L Achord, MD  Professor Emeritus, Department of Medicine, Division of Digestive Diseases, University of Mississippi School of Medicine

James L Achord, MD is a member of the following medical societies: American Association for the Study of Liver Diseases, American College of Gastroenterology, American College of Physicians, American Gastroenterological Association, American Medical Association, American Society for Gastrointestinal Endoscopy, Mississippi State Medical Association, New York Academy of Sciences, Sigma Xi, and Southern Medical Association

Disclosure: Nothing to disclose.

Alex J Mechaber, MD, FACP  Senior Associate Dean for Undergraduate Medical Education, Associate Professor of Medicine, University of Miami Miller School of Medicine

Alex J Mechaber, MD, FACP is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians-American Society of Internal Medicine, and Society of General Internal Medicine

Disclosure: Nothing to disclose.

Chief Editor

Julian Katz, MD  Clinical Professor of Medicine, Drexel University College of Medicine; Consulting Staff, Department of Medicine, Section of Gastroenterology and Hepatology, Hospital of the Medical College of Pennsylvania

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, and Physicians for Social Responsibility

Disclosure: Nothing to disclose.

References

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

  2. Hanau LH, Steigbigel NH. Acute (ascending) cholangitis. Infect Dis Clin North Am. Sep 2000;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. Jul 1999;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. Jan 1994;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. Jan 28 2006;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. Nov 1991;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. Nov 1995;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. Jun 2000;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. Jul 2005;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. Feb 2000;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. Jun 1994;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. Nov-Dec 2000;47(36):1531-2. [Medline].

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

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

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

  17. Liver Transplantation. Posttransplant biliary complications in the pre- and post-model for end-stage liver disease era. Apr 2011;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. Apr 1989;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. Jan 2000;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. Nov 2007;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. Aug 2005;37(8):715-21. [Medline].

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

  23. Mansfield JC, Griffin SM, Wadehra V, Matthewson K. A prospective evaluation of cytology from biliary strictures. Gut. May 1997;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. Sep 2004;99(9):1675-81. [Medline].

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

  26. [Best Evidence] Best Evidence: 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. Feb 2009;144(2):180-7. [Medline].

  27. [Best Evidence] Best Evidence: 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. Aug 2008;15(8):718-22. [Medline].

  28. Bismuth H, Nakache R, Diamond T. Management strategies in resection for hilar cholangiocarcinoma. Ann Surg. Jan 1992;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. Mar 2004;99(3):502-8. [Medline].

  30. Brugge WR. Endoscopic techniques to diagnose and manage biliary tumors. J Clin Oncol. Jul 10 2005;23(20):4561-5. [Medline].

  31. Bueno JT, Gerdes H, Kurtz RC. Endoscopic management of occluded biliary Wallstents: a cancer center experience. Gastrointest Endosc. Dec 2003;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. Nov 1996;183(5):506-13. [Medline].

  33. Gibbons JC, Williams SJ. Progress in the endoscopic management of benign biliary strictures. J Gastroenterol Hepatol. Feb 1998;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. Nov-Dec 1998;45(24):2048-50. [Medline].

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

  36. Kadir S, White RI Jr. Biliary stricture dilatation: multicenter review of clinical management in 73 patients. Radiology. Jan 1987;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. May 2008;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. Nov 1994;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. Nov 1991;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. Aug 1995;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. Oct 1995;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. Dec 1998;93(12):2482-90. [Medline].

  44. Moore AV Jr, Illescas FF, Mills SR, et al. Percutaneous dilation of benign biliary strictures. Radiology. Jun 1987;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. Nov 1990;28(6):1191-201. [Medline].

  46. Nealon WH, Urrutia F. Long-term follow-up after bilioenteric anastomosis for benign bile duct stricture. Ann Surg. Jun 1996;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. Oct 1996;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. Sep 2004;60(3):390-6. [Medline].

  49. Roslyn JJ, Binns GS, Hughes EF. Open cholecystectomy. A contemporary analysis of 42,474 patients. Ann Surg. Aug 1993;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. Feb 2006;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. Jun 1996;83(6):764-8. [Medline].

  52. Tenner S, Roston A, Lichtenstein D, et al. Eosinophilic cholangiopathy. Gastrointest Endosc. Mar 1997;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. Feb 2000;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. Jun 1996;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. Oct 1996;10(10):970-3. [Medline].

 
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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.
 
 
 
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