eMedicine Specialties > Gastroenterology > Biliary

Bile Duct Strictures: Treatment & Medication

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

Treatment

Medical Care

Medical treatment consists of managing complications of bile duct strictures until definitive therapy can be instituted. Most patients who present with cholangitis have a response to antibiotics and supportive management. Patients who are elderly and frail and those presenting with hypotension or altered mental status are best treated in an intensive care unit.

  • The common organisms that cause cholangitis are Escherichia coli and Klebsiella, Enterococcus, Proteus, Bacteroides, and Clostridium species. Empiric antibiotic therapy should be effective against these organisms.
  • Traditionally, a combination of a penicillin, aminoglycoside (gentamicin), and metronidazole has been the preferred regimen. Newer penicillins, such as piperacillin/tazobactam or imipenem/cilastatin, also have excellent activity against anaerobes, enterococci, and gram-negative cocci.
  • Approximately 70-80% of patients' conditions respond to medical therapy and do not need urgent intervention. Patients not having a response to empiric antibiotic therapy within 24 hours or those with hypotension requiring vasopressors, disseminated intravascular coagulation, or multiorgan system failure should be considered for immediate biliary decompression, which can be performed surgically, percutaneously, or endoscopically. Endoscopic or percutaneous decompression is often associated with lower morbidity and should be considered first.

Surgical Care

Patients with cholangitis whose conditions fail to improve with conservative treatment usually require urgent decompression of the obstructed biliary system. Treatment options for bile duct strictures (biliary strictures) include (1) endoscopic or percutaneous balloon dilatation and insertion of an endoprosthesis or (2) surgery.

  • Decompression of the biliary system
    • Decompression is usually performed endoscopically, with placement of a nasobiliary tube or stent after sphincterotomy.
    • Alternatives to ERCP are percutaneous transhepatic biliary drainage and surgical decompression. However, operative biliary decompression is associated with much higher morbidity and mortality compared with endoscopic therapy.
  • Endoscopic management
    • Benign biliary strictures (eg, postcholecystectomy, after liver transplantation) can be treated effectively with endoscopic therapy, which achieves a symptomatic and biochemical response in most cases.
    • Studies have shown that the long-term success rate of endoscopic stenting is comparable to that of surgery, with similar recurrence rates. Therefore, surgery should probably be reserved for those patients with complete ductal obstruction or for those in whom endoscopic therapy has failed.
    • Endoscopic therapy generally involves a sphincterotomy, which is performed at the first endoscopic session simultaneously with the placement of one or two 10F-12F stents across the area of obstruction. Dilatation of the stricture may be necessary if the stricture is too tight.
    • The insertion of a second stent may be possible only during a second endoscopy session. Thereafter, elective replacement of the stents seems desirable to prevent cholangitis by stent occlusion because polyethylene stents generally clog in 3-4 months.
  • Sphincterotomy and endoscopic balloon dilatation
    • The combination of sphincterotomy and endoscopic balloon dilatation alone is not a reliable method of treating benign strictures.
    • Percutaneous treatment by balloon dilatation followed by short- to intermediate-term stent placement appears to provide a more durable result.
  • Endoscopic biliary stenting
    • This procedure is an alternative to surgery for the initial treatment of jaundice and cholangitis in patients with bile duct strictures (biliary strictures) due to chronic pancreatitis.
    • The morbidity and mortality rates associated with biliary stent insertion are low. Endoscopic therapy appears to be effective in this situation; however, the efficacy of this treatment in the long-term management of bile duct strictures (biliary strictures) from pancreatitis is limited by frequent stent blockages and migration and should be considered an alternative to surgery only in high-risk surgical candidates.
    • The role of metallic stents in this situation needs further evaluation. Opinions vary considerably regarding the clinical significance of bile duct strictures (biliary strictures) secondary to pancreatitis in asymptomatic patients and the appropriate treatment of these lesions. The low incidence of cholangitis and secondary biliary cirrhosis in association with asymptomatic bile duct strictures (biliary strictures) may justify a less aggressive approach.
  • Endoscopic therapy for PSC
    • Endoscopic therapy of PSC is palliative. The main goal is to improve pruritus and relieve jaundice before transplantation.
    • The treatment involves balloon dilatation of strictures, stone removal, and placement of plastic stents.
    • Endoscopic stent therapy is a safe and effective treatment modality for an acute exacerbation of disease caused by dominant extrahepatic bile duct strictures (biliary strictures) in patients with PSC. Stent therapy is generally not effective for multiple intrahepatic ductal strictures.
    • In carefully selected patients with PSC who do not have cirrhosis, resection and long-term stenting remain good options. Patients with cirrhosis should undergo liver transplantation.
    • The role of endoscopy in the treatment of secondary biliary stricture associated with conditions such as HIV infection remains undefined. These patients have advanced AIDS; however, AIDS-related cholangitis per se rarely causes death. ERCP and sphincterotomy may help to relieve an individual patient's pain and improve quality of life.
  • Endoscopic therapy for malignant strictures
    • The treatment of malignant bile duct strictures (biliary strictures) requires consideration of a number of factors, the most important being the extremely low survival and cure rates associated with the disease. Most patients die from malignant bile duct strictures within 6-12 months.
    • The primary objective in unresectable disease is to provide palliation of the jaundice. Given the morbidity and mortality associated with an operative procedure, nonoperative techniques of palliation are preferred.
    • Self-expanding metal stents provide effective palliation of malignant biliary strictures and should be considered as an alternative to open surgery.
    • Metallic stents, although more expensive and not removable once placed, remain patent longer than polyethylene stents; usually a single session of metal stenting can palliate biliary obstruction and, therefore, may be a better choice for the treatment of malignant strictures.
    • With tumors affecting the bifurcation of the hepatic ducts (Klatskin tumor) (see Image 1 or below), stents can be placed into both the right and left intrahepatic ducts to provide decompression. However, stent placement is technically more difficult in patients with proximal tumors.
    • Metal stents may become occluded as a result of tumor ingrowth through the open mesh design. A covered, self-expanding metal has been introduced in an effort to reduce the frequency of tumor ingrowth.
  • Percutaneous transhepatic cholangioplasty and biliary stenting
    • Similar to endoscopy, the percutaneous balloon dilatation of benign (especially after OLT) and malignant bile duct strictures (biliary strictures) and the insertion of plastic or metallic stents are also well tolerated by patients. The stents provide good drainage.
    • This procedure is executed in a few stages as the tract through the liver is dilated gradually to pass the optimal-size stent. The stent may be completely internalized, with one lumen in the duodenum and the other proximal to the stricture, or it may be an internal-external stent, with one lumen outside and one distal to the stricture.
    • Percutaneous therapy is associated with a 5-10% rate of major complications.
  • Operative treatment
    • Surgical management of benign bile duct strictures (biliary strictures) is necessary for patients with a low surgical risk in whom endoscopic therapy has failed. Surgical management consists of restoration of biliary enteric continuity, which usually is achieved with a defunctionalized Roux-en-Y jejunal loop by means of hepaticojejunostomy, choledochojejunostomy, or intrahepatic cholangiojejunostomy.
    • Biliary-enteric anastomosis is a safe, effective, and lasting therapy for biliary strictures. However, before definitive operative therapy for bile duct strictures (biliary strictures) is performed, patients must be stabilized and, if possible, biliary drainage should be achieved either endoscopically or percutaneously.
    • Patients with long-standing bile duct strictures (biliary strictures) due to pancreatitis may require pancreaticoduodenectomy. However, surgical drainage has been associated with considerable morbidity and mortality.
    • In patients with PSC without cirrhosis, resection of the extrahepatic bile ducts and long-term transhepatic stenting are alternatives to nonoperative dilation with or without stenting and may be associated with a better outcome.
    • Surgical therapy of malignant bile duct strictures (biliary strictures) consists of either attempting a curative resection of the tumor or performing a palliative operation. Unfortunately, the surgical cure rate of pancreatic, bile duct, and gallbladder carcinoma causing malignant strictures is dismal. Careful staging of the tumor should be performed in order to select patients who are likely to have surgically resectable disease.
    • Surgical intervention is recommended for those patients who are otherwise healthy, whose disease appears to be localized, or in whom duodenal or gastric outlet obstruction is present.
    • Palliative surgery is directed toward relieving jaundice by creating a biliary-enteric anastomosis, and if a gastric or duodenal outlet obstruction is present or a likely possibility, a gastrojejunostomy should be created at the same time. Although palliative surgery is effective in achieving its goal of circumventing the obstruction, no survival advantage has been described when compared with nonoperative techniques. Thus, for most patients, palliative surgery is not necessary.

Consultations

  • Gastroenterologist
  • Surgeon
  • Infectious disease specialist
  • Interventional radiologist
  • Oncologist

Diet

  • No special diet is required for those with bile duct strictures (biliary strictures).

Activity

  • No restriction on physical activity is required of individuals with bile duct strictures (biliary strictures).

Medication

The goals of pharmacotherapy iin those with bile duct strictures (biliary strictures) are to eradicate the infection, prevent complications, and reduce morbidity.

Antibiotics

Empiric antimicrobial therapy must be comprehensive and should cover all likely pathogens in the context of this clinical setting.


Piperacillin and tazobactam sodium (Zosyn)

Antipseudomonal penicillin plus beta-lactamase inhibitor. Inhibits biosynthesis of cell wall mucopeptide and is effective during stage of active multiplication.

Adult

3/0.375 g (piperacillin 3 g and tazobactam 0.375 g) IV q6h

Pediatric

Not established

Tetracyclines may decrease effects of ticarcillin; high concentrations of ticarcillin may physically inactivate aminoglycosides if administered in the same IV line; effects when administered concurrently with aminoglycosides are synergistic; probenecid may increase penicillin levels.

Documented hypersensitivity; severe pneumonia; bacteremia; pericarditis; emphysema; meningitis and purulent or septic arthritis should not be treated with an oral penicillin during the acute stage

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Perform CBC count before the initiation of therapy and at least weekly during therapy; monitor for liver function abnormalities by measuring AST and ALT during therapy; exercise caution in patients diagnosed with hepatic insufficiencies; perform urinalysis and BUN and creatinine determinations during therapy, and adjust the dose if values become elevated; monitor blood levels to avoid possible neurotoxic reactions.


Imipenem and cilastatin (Primaxin)

For the treatment of multiple-organism infections in which other agents do not have broad-spectrum coverage or are contraindicated due to potential toxicity.

Adult

1 g IV/IM q6-8h

Pediatric

<12 years: Not established

>12 years: Administer as in adults.

Coadministration with cyclosporine may increase the adverse CNS effects of both agents; coadministration with ganciclovir may result in generalized seizures.

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Adjust dose in the presence of renal insufficiency.


Metronidazole (Flagyl, Protostat)

Imidazole ring-based antibiotic active against various anaerobic bacteria and protozoa. Used in combination with other antimicrobial agents (except for Clostridium difficile enterocolitis).

Adult

500 mg IV q6-8h

Pediatric

Not established

May increase the toxicity of anticoagulants, lithium, and phenytoin; cimetidine may increase toxicity; disulfiram reaction may occur with orally ingested ethanol

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Adjust the dose in the presence of hepatic disease; monitor for seizures and the development of peripheral neuropathy.


Gentamicin (Garamycin, Gentacidin)

Aminoglycoside antibiotic for gram-negative coverage. Used in combination with both an agent against gram-positive organisms and one that covers anaerobes.
Not the DOC. Consider if penicillins or other less toxic drugs are contraindicated, when clinically indicated, and in mixed infections caused by susceptible staphylococci and gram-negative organisms.

Dosing regimens are numerous; adjust the dose based on CrCl and changes in volume of distribution. May be given IV/IM.

Adult

Loading dose: 1-2.5 mg/kg IV

Maintenance dose: 1-1.5 mg/kg IV q8h

Extended dosing regimen for life-threatening infections: 5 mg/kg/d IV/IM q6-8h

Monitor each regimen by drawing at least a trough level on the third or fourth dose (0.5 h before dosing); may draw a peak level 0.5 h after 30-min infusion

Pediatric

Not established

Coadministration with other aminoglycosides, cephalosporins, penicillins, and amphotericin B may increase nephrotoxicity; because aminoglycosides enhance the effects of neuromuscular blocking agents, prolonged respiratory depression may occur; coadministration with loop diuretics may increase the auditory toxicity of aminoglycosides; possible irreversible hearing loss of varying degrees may occur (monitor regularly)

Documented hypersensitivity; non–dialysis-dependent renal insufficiency

Pregnancy

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Narrow therapeutic index (not intended for long-term therapy); caution in patients with renal failure (not on dialysis), myasthenia gravis, hypocalcemia, and conditions that depress neuromuscular transmission; adjust the dose in the presence of renal impairment


Penicillin G (Pfizerpen)

Interferes with synthesis of cell wall mucopeptide during active multiplication, resulting in bactericidal activity against susceptible microorganisms.

Adult

2.4 million U IM (single dose) in 2 injection sites

Pediatric

Not established

Probenecid can increase effects; coadministration of tetracyclines can decrease effects

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Caution in patients with impaired renal function

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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