eMedicine Specialties > Gastroenterology > Biliary

Bile Duct Strictures: Follow-up

Author: William R Brugge, MD, Professor of Medicine, Harvard Medical School; Director, Gastrointestinal Endoscopy Unit, Massachusetts General Hospital
Coauthor(s): Ashraf Saleemuddin, MD, Staff Physician, Department of Internal Medicine, Boston University Medical Center; Hemant Pande, MD, Consulting Staff, Department of Gastroenterology, Leesville Surgical Clinic and Digestive Disease Center; 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; Lawrence J Cheskin, MD, Associate Professor, International Health/Human Nutrition, JH Bloomberg School of Public Health; Joint Appointment, Department of Medicine, Division of Gastroenterology, Johns Hopkins University School of Medicine
Contributor Information and Disclosures

Updated: Mar 27, 2009

Follow-up

Further Inpatient Care

  • Patients with bile duct strictures (biliary strictures) who develop obstructive jaundice complicated by fever, infection, or duodenal obstruction are often admitted for urgent inpatient treatment of obstruction and/or infection.
  • Patients presenting with ascending cholangitis may need to be admitted to the intensive care unit, especially if they have altered mental status and hypotension. These patients should be started on broad-spectrum antibiotics with good gram-negative and anaerobic coverage.
  • In addition, urgent drainage and decompression of the biliary tree may be required when an appropriate response to antibiotic therapy is not achieved.
  • Patients with bile duct strictures (biliary strictures) amenable to endoscopic therapy can be treated in an inpatient or outpatient setting. Those requiring surgery generally have a longer hospital stay, especially in the postoperative period.

Further Outpatient Care

  • Patients with bile duct strictures (biliary strictures) with percutaneous drains should have their catheters flushed with 5-10 mL of saline once or twice every day to prevent catheter blockage.
  • Patients should be monitored closely for recurrence of cholangitis and obstructive jaundice, which can occur if the biliary drainage catheters or stents are occluded or if they migrate.
  • Those treated with biliary stenting with plastic stents or balloon dilatation of bile duct strictures (biliary strictures) need periodic follow-up with a gastroenterologist or interventional radiologist for stent changes and periodic stricture dilatation.
  • Patients with external biliary drains should also seek follow-up with an interventional radiologist for catheter exchanges every 2-3 months for internalization of drains.
  • Those with a malignant obstruction treated with metallic endoprosthesis should be monitored with periodic liver function testing. Progressively abnormal liver function tests suggest stent dysfunction.

Transfer

  • Management of bile duct strictures (biliary strictures) is a complex problem requiring a multidisciplinary approach. The patient should be in a specialized center where expertise in diagnostic and therapeutic ERCP and biliary interventional radiology is available. Surgical therapy should also be performed in centers with staff experienced in performing hepatobiliary and pancreatic surgery.

Complications

  • Complications of bile duct strictures (biliary strictures) include development of stones in the gallbladder and bile ducts proximal to the stricture, pyogenic liver abscess due to recurrent episodes of ascending cholangitis, secondary biliary cirrhosis, and weight loss and malnutrition from steatorrhea with fat-soluble vitamin deficiency.

Prognosis

  • The prognosis for patients with benign bile duct strictures (biliary strictures) is good. Patients who develop symptoms of biliary obstruction do well after surgical or endoscopic therapy.
  • Conversely, patients with HIV cholangiopathy or malignant biliary obstruction usually present at a late stage with widespread disease, and they generally have a dismal prognosis.

Patient Education

  • Patients with biliary stents should be educated regarding how to recognize the symptoms of biliary obstruction and cholangitis that indicate blocked stents. Those with external drains should be taught how to flush their catheters until the catheters are internalized.
  • Patients with alcoholic chronic pancreatitis may benefit from counseling and alcohol abuse rehabilitation.

Miscellaneous

Medicolegal Pitfalls

  • Patients presenting with acute ascending cholangitis should undergo urgent biliary drainage when an appropriate response to antibiotic therapy is not achieved or when the initial presentation is severe.
 


More on Bile Duct Strictures

Overview: Bile Duct Strictures
Differential Diagnoses & Workup: Bile Duct Strictures
Treatment & Medication: Bile Duct Strictures
Follow-up: Bile Duct Strictures
Multimedia: Bile Duct Strictures
References
Further Reading
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Further Reading

Best Evidence

Clinical Trials

National Guidelines Clearinghouse

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Keywords

bile duct strictures, biliary stricture, biliary stenosis, bile duct stenosis, bile duct constriction,  operative trauma, surgical trauma, ascending cholangitis, liver abscess, secondary biliary cirrhosis, pancreatic cancer, benign strictures, malignant strictures, bile duct injury, pancreatitis, bile duct stones, choledocholithiasis, primary sclerosing cholangitis, PSC, postoperative bile duct stricture, cholecystectomy, Charcot triad, cholangiocarcinoma

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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, Associate Professor, International Health/Human Nutrition, JH Bloomberg School of Public Health; Joint Appointment, Department of Medicine, Division of Gastroenterology, Johns Hopkins University School of Medicine
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; Pharmaceutical Companies Honoraria Speaking and teaching

Medical Editor

David Greenwald, MD, Fellowship Program Director, Associate Professor, 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, and American Society for Gastrointestinal Endoscopy
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

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.

CME Editor

Alex J Mechaber, MD, FACP, 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 and Ethics, American Trauma Society, Association of American Medical Colleges, and Physicians for Social Responsibility
Disclosure: Nothing to disclose.

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