eMedicine Specialties > Gastroenterology > Biliary

Biliary Obstruction: Follow-up

Author: Jennifer Lynn Bonheur, MD, Attending Physician, Division of Gastroenterology, Lenox Hill Hospital
Coauthor(s): Peter F Ells, MD, Associate Professor, Division of Gastroenterology-Hepatology, Albany Medical Center
Contributor Information and Disclosures

Updated: Aug 29, 2009

Follow-up

Further Inpatient Care

  • Admit the patient for prompt necessary diagnostic testing, supportive care, and surgical intervention if indicated.

Further Outpatient Care

  • Monitor patients regularly to ensure that they respond to treatment and that the diagnosis is correct.

Inpatient & Outpatient Medications

  • The same medications are used in both outpatient and inpatient settings.

Transfer

  • Transfer may be required for further diagnostic evaluation and treatment.

Deterrence/Prevention

  • In patients with risk factors for developing any of the conditions that lead to biliary obstruction, awareness of the signs and symptoms can improve chances for early diagnosis and improved outcome.
  • Gallstones are the most common cause of biliary obstruction. Estrogens cause an increase in the risk for formation of gallstones and may need to be avoided in patients with known gallstones or a strong family history of stone disease.

Complications

  • The complications of cholestasis are proportional to the duration and intensity of the jaundice.
  • High-grade biliary obstruction begins to cause cell damage after approximately 1 month and, if unrelieved, may lead to secondary biliary cirrhosis.
  • Acute cholangitis is another complication associated with obstruction of the biliary tract and is the most common complication of a stricture, most often at the level of the CBD. Bile normally is sterile. In the presence of obstruction to flow, stasis favors colonization and multiplication of bacteria within the bile. Concomitant increased intraductal pressure can lead to the reflux of biliary contents and bacteremia, which can cause septic shock and death. For this reason, medical treatment of the patient with cholangitis serves only as a temporizing measure. Long-term relief of the biliary obstruction, whether it be surgical, percutaneous, or endoscopic, is necessary to prevent an adverse outcome.8
  • Patients with biliary obstruction who undergo biliary tract surgery may develop postoperative acute oliguric renal failure. The complication may be due to nephrotoxic bile salts and pigments, endotoxins, or inflammatory mediators. Elderly patients who are deeply jaundiced are more likely to develop postoperative oliguric renal failure than patients of the same age without jaundice.
  • Biliary colic that recurs at any point after a cholecystectomy should prompt evaluation for possible choledocholithiasis.
  • Failure of bile salts to reach the intestine results in fat malabsorption with steatorrhea. In addition, the fat-soluble vitamins A, D, E, and K are not absorbed, resulting in vitamin deficiencies. Disordered hemostasis with an abnormally prolonged PT may further complicate the course of these patients. Cholestyramine and colestipol, used to treat pruritus, bind to bile salts and can exacerbate these vitamin deficiencies.
  • Persistent cholestasis from any cause may be associated with deposits of cholesterol in the skin (cutaneous xanthomatosis) and, occasionally, in bones and peripheral nerves.

Prognosis

  • The prognosis depends on the cause of biliary obstruction.

Patient Education

  • Awareness of the risk factors and clinical signs/symptoms of biliary obstruction is key to the prompt diagnosis and treatment of biliary obstruction, with the hope of preventing the potential complications it may cause.
  • For excellent patient education resources, visit eMedicine's Liver, Gallbladder, and Pancreas Center and Cholesterol Center. Also, see eMedicine's patient education articles Gallstones and Cirrhosis.

Miscellaneous

Medicolegal Pitfalls

  • Once a diagnosis has been made, the physician has the responsibility to ensure that the patient responds to the appropriate therapy. If no response occurs, reevaluate the patient to make sure other causes of biliary obstruction are not missed.

Special Concerns

Patients status post-gastric bypass:
In patients who have undergone gastrointestinal bypass surgery (for example gastrojejunostomy, hepatojejunostomy, biliopancreatic diversion) the normal anatomy is surgically altered precluding ERCP using standard equipment. In such cases, double balloon enteroscopy (DBE) has been studied as a potential way to overcome endoscopic limitations and enable ERCP in patients with biliary obstruction.9,10 DBE is an advanced endoscopic technique  which was developed to endoscopically evaluate the small bowel. It requires specialized training in order to perform routinely and, in particular, when it is utilized for ERCP.

 
Acknowledgments

The authors and editors of eMedicine gratefully acknowledge the contributions of previous coauthor Flavio R Kamenetz, MD, PhD, to the development and writing of this article.



More on Biliary Obstruction

Overview: Biliary Obstruction
Differential Diagnoses & Workup: Biliary Obstruction
Treatment & Medication: Biliary Obstruction
Follow-up: Biliary Obstruction
References
Further Reading
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Further Reading



Related eMedicine Topics

Clinical Trials

National Guideline Clearinghouse

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Keywords

biliary obstruction, bile duct obstruction, biliary tract disorders, biliary tree, common bile duct, CBD, gallstones, gall stones, cholecystitis, cholecystectomy, cholelithiasis, cholestasis, drug-induced cholestasis, biliary cirrhosis, alcoholic liver disease, liver disease, exocrine secretion, hepatocellular disease, viral hepatitis, drug-induced hepatitis, malignancy, pancreatitis, hyperbilirubinemia, jaundice, icterus, stone disease, biliary stricture, parasites, primary sclerosing cholangitis, PSC, AIDS-related cholangiopathy, biliary tuberculosis, cystic duct stones, Mirizzi syndrome, sump syndrome

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Contributor Information and Disclosures

Author

Jennifer Lynn Bonheur, MD, Attending Physician, Division of Gastroenterology, Lenox Hill Hospital
Jennifer Lynn Bonheur, MD is a member of the following medical societies: American Gastroenterological Association, American Society for Gastrointestinal Endoscopy, New York Academy of Sciences, New York Society for Gastrointestinal Endoscopy, and Sigma Xi
Disclosure: Nothing to disclose.

Coauthor(s)

Peter F Ells, MD, Associate Professor, Division of Gastroenterology-Hepatology, Albany Medical Center
Disclosure: Nothing to disclose.

Medical Editor

Anil Minocha, MD, FACP, FACG, Clinical Professor, School of Pharmacy, Professor of Medicine, Director of Digestive Diseases, Medical Director of Nutrition Support, Medical Director of Gastrointestinal Endoscopy, Internal Medicine Department, University of Mississippi Medical Center
Anil Minocha, MD, FACP, FACG is a member of the following medical societies: American Academy of Clinical Toxicology, American Association for the Study of Liver Diseases, American College of Forensic Examiners, American College of Gastroenterology, American College of Physicians, American Federation for Clinical Research, American Gastroenterological Association, and American Society of Gastrointestinal Endoscopy
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

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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