eMedicine Specialties > Gastroenterology > Biliary

Bile Duct Strictures

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

Introduction

Background


Bile duct stricture (biliary stricture) is an uncommon but challenging clinical condition that requires a coordinated multidisciplinary approach involving gastroenterologists, radiologists, and surgical specialists. Unfortunately, most benign bile duct strictures (biliary strictures) are iatrogenic, resulting from operative trauma (see Images 10 and 15 or below).1 Bile duct strictures (biliary strictures) may be asymptomatic but, if ignored, can cause life-threatening complications, such as ascending cholangitis,2,3 liver abscess, and secondary biliary cirrhosis.

Focal intrahepatic benign bile duct stricture aft...

Focal intrahepatic benign bile duct stricture after cholecystectomy.

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Focal intrahepatic benign bile duct stricture aft...

Focal intrahepatic benign bile duct stricture after cholecystectomy.


Percutaneous transhepatic cholangiogram with ball...

Percutaneous transhepatic cholangiogram with balloon dilation of a postoperative bile duct stricture.

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Percutaneous transhepatic cholangiogram with ball...

Percutaneous transhepatic cholangiogram with balloon dilation of a postoperative bile duct stricture.


However, not all bile duct strictures (biliary strictures) are benign. Pancreatic cancer is the most common cause of malignant biliary strictures (see Images 6 and 14 or below).4,5 Most of these patients die of complications of tumor invasion and metastasis rather than from the bile duct stricture (biliary stricture) per se. Nonetheless, both benign and malignant bile duct strictures can be associated with distressing symptoms and excessive morbidity.6

Endoscopic retrograde cholangiopancreatographic c...

Endoscopic retrograde cholangiopancreatographic cholangiogram demonstrating an isolated mid-hepatic duct stricture as a result of pancreatic cancer.

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Endoscopic retrograde cholangiopancreatographic c...

Endoscopic retrograde cholangiopancreatographic cholangiogram demonstrating an isolated mid-hepatic duct stricture as a result of pancreatic cancer.


Focal bile duct stricture as a result of pancreat...

Focal bile duct stricture as a result of pancreatic cancer in the head of the pancreas.

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Focal bile duct stricture as a result of pancreat...

Focal bile duct stricture as a result of pancreatic cancer in the head of the pancreas.


For excellent patient education resources, visit eMedicine's Liver, Gallbladder, and Pancreas Center and Hepatitis Center. Also, see eMedicine's patient education articles Cirrhosis and Gallstones.

Pathophysiology

Strictures of the bile duct can be benign or malignant. Benign strictures develop when the bile ducts are injured in some way. The injury may be a single acute event, such as damage to the bile ducts during surgery or trauma to the abdomen; a recurring condition, such as pancreatitis or bile duct stones; or a chronic disease, such as primary sclerosing cholangitis (PSC). After the injury, an inflammatory response ensues, which is followed by collagen deposition, fibrosis, and narrowing of the bile duct lumen (see Images 5 and 7, as well as Images 8-9, or below).

Endoscopic retrograde cholangiopancreatographic c...

Endoscopic retrograde cholangiopancreatographic cholangiogram of a solitary benign stricture of the distal bile duct. Resection demonstrated sclerosing cholangitis.

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Endoscopic retrograde cholangiopancreatographic c...

Endoscopic retrograde cholangiopancreatographic cholangiogram of a solitary benign stricture of the distal bile duct. Resection demonstrated sclerosing cholangitis.


Endoscopic retrograde cholangiopancreatographic c...

Endoscopic retrograde cholangiopancreatographic cholangiogram demonstrating diffuse stricturing of the intrahepatic ducts that is consistent with primary sclerosing cholangitis.

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Endoscopic retrograde cholangiopancreatographic c...

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 sc...

Periductal onion skin fibrosis seen in primary sclerosing cholangitis.

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Periductal onion skin fibrosis seen in primary sc...

Periductal onion skin fibrosis seen in primary sclerosing cholangitis.


Periductal lymphocytic and plasma cell infiltrate...

Periductal lymphocytic and plasma cell infiltrate that is consistent with autoimmune cholangiopathy.

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Periductal lymphocytic and plasma cell infiltrate...

Periductal lymphocytic and plasma cell infiltrate that is consistent with autoimmune cholangiopathy.


Depending on the nature of the insult, bile duct strictures (biliary strictures) can be single or multiple. Atrophy of the hepatic segment or lobe drained by the involved bile ducts, associated with hypertrophy of the unaffected segments, can occur, especially with chronic high-grade strictures. These changes can eventually progress to secondary biliary cirrhosis and portal hypertension.

Malignant strictures are usually the result of either a primary bile duct cancer (ie, causing a narrowing of the bile duct lumen and obstructing the flow of bile) or extrinsic compression of the bile ducts by a neoplasm in an adjacent organ, such as the gallbladder, pancreas, or liver (see Image 2 or below).

Endoscopic retrograde cholangiopancreatographic c...

Endoscopic retrograde cholangiopancreatographic cholangiogram demonstrating a long bile duct stricture that represents external compression by gallbladder cancer.

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Endoscopic retrograde cholangiopancreatographic c...

Endoscopic retrograde cholangiopancreatographic cholangiogram demonstrating a long bile duct stricture that represents external compression by gallbladder cancer.


Frequency

United States

Although quite uncommon, the exact prevalence of bile duct strictures (biliary strictures) is unknown. One major category of bile duct strictures is postoperative bile duct stricture, which usually occurs as a result of a technical mishap during cholecystectomy, causing bile duct injury. Data from many large series of patients in the United States have revealed that the incidence rate of major bile duct injury is 0.2-0.3% after open cholecystectomy and 0.4-0.6% after a laparoscopic cholecystectomy.

International

Data from Europe have shown a similar rate to the United States of occurrence of postoperative bile duct strictures.

Mortality/Morbidity

  • Bile duct strictures, independent of etiology, can cause significant morbidity from recurrent obstructive jaundice, right upper quadrant abdominal pain, biliary stones, and recurrent episodes of ascending cholangitis (see Image 11 or below).
    Multiple small bile duct stones seen on magnetic ...

    Multiple small bile duct stones seen on magnetic resonance cholangiopancreatography (MRCP).

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    Multiple small bile duct stones seen on magnetic ...

    Multiple small bile duct stones seen on magnetic resonance cholangiopancreatography (MRCP).

  • The major determinant of mortality in patients with bile duct strictures is the underlying disease condition. Patients with biliary strictures due to operative injury, radiation, trauma, or chronic pancreatitis generally have a good prognosis. Conversely, patients with bile duct strictures due to PSC and malignancy have a less favorable outcome.

Sex

  • Data on the overall sex ratio of bile duct strictures are lacking. Some conditions causing bile duct strictures, such as PSC and chronic pancreatitis, are more common in men. The incidence of postcholecystectomy strictures is comparable in men and women.

Clinical

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) infection14,15 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).

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.

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.
    • 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).
    • Radiation12,13 : 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.
    • Tuberculosis17 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 1 or below).
      Endoscopic retrograde cholangiopancreatographic i...

      Endoscopic retrograde cholangiopancreatographic image of a cholangiocarcinoma at the bifurcation of the right and left hepatic ducts (Klatskin tumor).

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      Endoscopic retrograde cholangiopancreatographic i...

      Endoscopic 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.

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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