Bile Duct Strictures Follow-up

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

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.
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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.
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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.
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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.
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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.
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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.
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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.

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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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