Biliary Obstruction 

  • Author: Jennifer Lynn Bonheur, MD; Chief Editor: Julian Katz, MD   more...
 
Updated: Jan 5, 2012
 

Background

Disorders of the biliary tract affect a significant portion of the worldwide population, and the overwhelming majority of cases are attributable to cholelithiasis (gallstones). In the United States, 20% of persons older than 65 years have gallstones and 1 million newly diagnosed cases of gallstones are reported each year.

To better understand these disorders, a brief discussion of the normal structure and function of the biliary tree is needed. Bile is the exocrine secretion of the liver and is produced continuously by hepatocytes. It contains cholesterol and waste products, such as bilirubin and bile salts, which aid in the digestion of fats. Half the bile produced runs directly from the liver into the duodenum via a system of ducts, ultimately draining into the common bile duct (CBD). The remaining 50% is stored in the gallbladder. In response to a meal, this bile is released from the gallbladder via the cystic duct, which joins the hepatic ducts from the liver to form the CBD. The CBD courses through the head of the pancreas for approximately 2 cm before passing through the ampulla of Vater into the duodenum.[1]

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Pathophysiology

Biliary obstruction refers to the blockage of any duct that carries bile from the liver to the gallbladder or from the gallbladder to the small intestine. This can occur at various levels within the biliary system. The major signs and symptoms of biliary obstruction result directly from the failure of bile to reach its proper destination.

The clinical setting of cholestasis or failure of biliary flow may be due to biliary obstruction by mechanical means or by metabolic factors in the hepatic cells. For the sake of simplicity, the primary focus of this article is mechanical causes of biliary obstruction, further separating them into intrahepatic and extrahepatic causes. The discussion of intracellular/metabolic causes of cholestasis is very complex, the pathogenesis of which is not always clearly defined. Therefore, these causes are mentioned but are not discussed in detail.

Intrahepatic cholestasis generally occurs at the level of the hepatocyte or biliary canalicular membrane. Causes include hepatocellular disease (eg, viral hepatitis, drug-induced hepatitis), drug-induced cholestasis, biliary cirrhosis, and alcoholic liver disease. In hepatocellular disease, interference in the 3 major steps of bilirubin metabolism, ie, uptake, conjugation, and excretion, usually occurs. Excretion is the rate-limiting step and is usually impaired to the greatest extent. As a result, conjugated bilirubin predominates in the serum.

Extrahepatic obstruction to the flow of bile may occur within the ducts or secondary to external compression. Overall, gallstones are the most common cause of biliary obstruction. Other causes of blockage within the ducts include malignancy, infection, and biliary cirrhosis. External compression of the ducts may occur secondary to inflammation (eg, pancreatitis) and malignancy. Regardless of the cause, the physical obstruction causes a predominantly conjugated hyperbilirubinemia.

Accumulation of bilirubin in the bloodstream and subsequent deposition in the skin causes jaundice (icterus). Conjunctival icterus is generally a more sensitive sign of hyperbilirubinemia than generalized jaundice. Total serum bilirubin values are normally 0.2-1.2 mg/dL. Jaundice may not be clinically recognizable until levels are at least 3 mg/dL.[2] Urine bilirubin is normally absent. When it is present, only conjugated bilirubin is passed into the urine. This may be evidenced by dark-colored urine seen in patients with obstructive jaundice or jaundice due to hepatocellular injury. However, reagent strips are very sensitive to bilirubin, detecting as little as 0.05 mg/dL. Thus, urine bilirubin may be found before serum bilirubin reaches levels high enough to cause clinical jaundice.

The lack of bilirubin in the intestinal tract is responsible for the pale stools typically associated with biliary obstruction. The cause of itching (pruritus) associated with biliary obstruction is not clear. Some believe it may be related to the accumulation of bile acids in the skin. Others suggest it may be related to the release of endogenous opioids.

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Epidemiology

Frequency

United States

The incidence of biliary obstruction is approximately 5 cases per 1000 people.

Mortality/Morbidity

The mortality and morbidity of biliary obstruction depend on the cause of the obstruction.

Race

The racial predilection depends on the cause of the biliary obstruction.

  • Gallstones are the most common cause of biliary obstruction. Persons of Hispanic origin and Northern Europeans have a higher risk of gallstones compared to people from Asia and Africa.
  • Native Americans (particularly Pima Indians) have an increased incidence of obesity and diabetes within their population and are especially prone to developing gallstones. Pima women have a lifetime chance of developing gallstones as high as 80%.

Sex

The sexual predilection depends on the specific cause of the biliary obstruction.

  • Gallstone disease is the most common cause of biliary obstruction. Women are much more likely to develop gallstones than men. By the sixth decade, almost 25% of American women develop gallstones, with as many as 50% of women aged 75 years developing gallstones. This increased risk is likely caused by the effect of estrogen on the liver, causing it to remove more cholesterol from the blood and diverting it into the bile.
  • Approximately 20% of men aged 75 years have gallstones, with more complicated disease courses occurring in those who have had cholecystectomies.
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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.

Specialty Editor Board

Anil Minocha, MD, FACP, FACG  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; Clinical Professor, University of Mississippi School of Pharmacy

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.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape 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

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.

Additional Contributors

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.

References

  1. Center SA. Diseases of the gallbladder and biliary tree. Vet Clin North Am Small Anim Pract. May 2009;39(3):543-98. [Medline].

  2. Marrelli D, Caruso S, Pedrazzani C, et al. CA19-9 serum levels in obstructive jaundice: clinical value in benign and malignant conditions. Am J Surg. Apr 16 2009;epub ahead of print. [Medline].

  3. Bektas M, Dokmeci A, Cinar K, et al. Endoscopic management of biliary parasitic diseases. Dig Dis Sci. Jun 10 2009;epub ahead of print. [Medline].

  4. Nanashima A, Abo T, Sakamoto I, et al. Three-dimensional cholangiography applying C-arm computed tomography in bile duct carcinoma: a new radiological technique. Hepatogastroenterology. May-Jun 2009;56(91-92):615-8. [Medline].

  5. Niu H, Gao W, Cheng J, Liu B, Li Y, Huang K, et al. Improvement of Percutaneous Transhepatic Biliary Internal-External Drainage and its Initial Experience in Patients with Malignant Obstruction of the Upper Biliary Tree. Hepatogastroenterology. Nov 24 2011;59(117):[Medline].

  6. Hanada K, Iiboshi T, Ishii Y. Endoscopic ultrasound-guided choledochoduodenostomy for palliative biliary drainage in cases with inoperable pancreas head carcinoma. Dig Endosc. Jul 2009;21 suppl 1:S75-8. [Medline].

  7. Maranki J, Hernandez AJ, Arslan B, et al. Interventional endoscopic ultrasound-guided cholangiography: long-term experience of an emerging alternative to percutaneous transhepatic cholangiography. Endoscopy. Jun 2009;41(6):532-8. [Medline].

  8. Mutignani M, Iacopini F, Perri V, et al. Endoscopic gallbladder drainage for acute cholecystitis: technical and clinical results. Endoscopy. Jun 2009;41(6):539-46. [Medline].

  9. Jaganmohan S, Lee JH. Self-expandable metal stents in malignant biliary obstruction. Expert Rev Gastroenterol Hepatol. Jan 2012;6(1):105-14. [Medline].

  10. Gwon DI, Ko GY, Sung KB, Yoon HK, Shin JH, Kim JH, et al. A novel double stent system for palliative treatment of malignant extrahepatic biliary obstructions: a pilot study. AJR Am J Roentgenol. Nov 2011;197(5):W942-7. [Medline].

  11. Lee JG. Diagnosis and management of acute cholangitis. Nat Rev Gastroenterol Hepatol. Aug 4 2009;[Medline].

  12. Chu YC, Yang CC, Yeh YH, Chen CH, Yueh SK. Double-balloon enteroscopy application in biliary tract disease-its therapeutic and diagnostic functions. Gastrointest Endosc. Jun 16 2008;[Medline].

  13. Aabakken L, Bretthauer M, Line PD. Double-balloon enteroscopy for endoscopic retrograde cholangiography in patients with a Roux-en-Y anastomosis. Endoscopy. Dec 2007;39(12):1068-71. [Medline].

  14. Adamek HE, Albert J, Weitz M. A prospective evaluation of magnetic resonance cholangiopancreatography in patients with suspected bile duct obstruction. Gut. Nov 1998;43(5):680-3. [Medline].

  15. Ahmed A, Cheung RC, Keeffe EB. Management of gallstones and their complications. Am Fam Physician. Mar 15 2000;61(6):1673-80, 1687-8. [Medline].

  16. American Society of Gastrointestinal Endoscopy. Technology status evaluation: magnetic resonance pancreatography. In: American Society of Gastrointestinal Endoscopy Clinical Guidelines. Oak Brook, Ill: ASGE; 1998.

  17. Bass NM. Sclerosing cholangitis and recurrent pyogenic cholangitis. In: Feldman M, ed. Sleisenger and Fordtran's Gastrointestinal and Liver Disease. 6th ed. Philadelphia: WB Saunders; 1998:1006-18.

  18. Beers MH, Berkow R. Hepatic and biliary disorders. In: Beers MH, Berkow R, eds. The Merck Manual of Diagnosis and Therapy. 17th ed. Whitehouse Station, NJ: Merck & Co; 1999:chap 46.

  19. Bilhartz MH, Horton JD. Gallstone disease and its complications. In: Feldman M, ed. Sleisenger and Fordtran's Gastrointestinal and Liver Disease. 6th ed. Philadelphia: WB Saunders; 1998:948-72.

  20. Cancado EL, Leitao RM, Carrilho FJ, Laudanna AA. Unexpected clinical remission of cholestasis after rifampicin therapy in patients with normal or slightly increased levels of gamma-glutamyl transpeptidase. Am J Gastroenterol. Sep 1998;93(9):1510-7. [Medline].

  21. Cotran RS, Kumar V, Robbins SL. The biliary system. In: Schoen FJ, ed. Robbins Pathologic Basis of Disease. 5th ed. Philadelphia: WB Saunders; 1994:883-96.

  22. Erickson RA, Garza AA. EUS with EUS-guided fine-needle aspiration as the first endoscopic test for the evaluation of obstructive jaundice. Gastrointest Endosc. Apr 2001;53(4):475-84. [Medline].

  23. Friedman LS. The liver, biliary tract, and pancreas. In: Tiernery LM, McPhee SJ, Papadakis MA, eds. Current Medical Diagnosis & Treatment. 39th ed. New York: McGraw-Hill; 2000:656-97.

  24. Fukuda Y, Tsuyuguchi T, Sakai Y. Diagnostic utility of peroral cholangioscopy for various bile-duct lesions. Gastrointest Endosc. Sep 2005;62(3):374-82.

  25. Hanau LH, Steigbigel NH. Acute (ascending) cholangitis. Infect Dis Clin North Am. Sep 2000;14(3):521-46. [Medline].

  26. Kaplan LM, Isselbacher KJ. Jaundice. In: Fauci AS, Longo DL, Kasper DL, Martin JB, Hauser SL, Braunwald E, Isselbacher KJ, Wilson JD, eds. Harrison's Principles of Internal Medicine. 14th ed. New York: McGraw-Hill; 1998:249-55.

  27. Kasiske BL, Keane WF. Laboratory assessment of renal disease: clearance, urinalysis, and renal biopsy. In: Brenner BM, ed. Brenner and Rector's The Kidney. 6th ed. WB Saunders; 2000:1143.

  28. Kok KY, Yapp SK. Tuberculosis of the bile duct: a rare cause of obstructive jaundice. J Clin Gastroenterol. Sep 1999;29(2):161-4. [Medline].

  29. Lewis JH. Drug-induced liver disease. Med Clin North Am. Sep 2000;84(5):1275-311, x. [Medline].

  30. Lindnor KD. Primary biliary cirrhosis. In: Feldman M, ed. Sleisenger and Fordtran's Gastrointestinal and Liver Disease. 6th ed. Philadelphia: WB Saunders; 1998:1279.

  31. Lopera JE, Soto JA, Munera F. Malignant hilar and perihilar biliary obstruction: use of MR cholangiography to define the extent of biliary ductal involvement and plan percutaneous interventions. Radiology. Jul 2001;220(1):90-6. [Medline].

  32. Luketic VA, Shiffman ML. Benign recurrent intrahepatic cholestasis. Clin Liver Dis. Aug 1999;3(3):509-28, viii. [Medline].

  33. Mallery S, Van Dam J. Advances in diagnostic and therapeutic endoscopy. Med Clin North Am. Sep 2000;84(5):1059-83. [Medline].

  34. Maze M, Bass N. Anesthesia and the hepatobiliary system. In: Miller R, ed. Anesthesia. 5th ed. New York: Churchill Livingstone; 2000:1968-9.

  35. Nissen D. Rifampin (002188). In: Mosby's Drug Consult 2002. 1st ed. Orlando, Fla: Harcourt Health Sciences; 2002.

  36. Ostroff JW, LaBerge JM. Endoscopic and radiologic treatment of biliary disease. In: Feldman M, ed. Sleisenger and Fordtran's Gastrointestinal and Liver Disease. 6th ed. Philadelphia: WB Saunders; 1998:1043.

  37. Paumgartner G. Nonsurgical management of gallstone disease. In: Feldman M, ed. Sleisenger and Fordtran's Gastrointestinal and Liver Disease. 6th ed. Philadelphia: WB Saunders; 1998:984-92.

  38. Ravel R. Liver and biliary tract tests. In: Ravel R, ed. Clinical Laboratory Medicine. 6th ed. St. Louis, Mo: Mosby-Year Book; 1995:309-29.

  39. Rossi RL, Traverso LW, Pimentel F. Malignant obstructive jaundice. Evaluation and management. Surg Clin North Am. Feb 1996;76(1):63-70. [Medline].

  40. Scheiman JM, Carlos RC, Barnett JL, et al. Can endoscopic ultrasound or magnetic resonance cholangiopancreatography replace ERCP in patients with suspected biliary disease? A prospective trial and cost analysis. Am J Gastroenterol. Oct 2001;96(10):2900-4. [Medline].

  41. Shaker R, Dua KS, Koch TR. Gastroenterologic disorders. In: Duthie EH, ed. Practice of Geriatrics. 3rd ed. Philadelphia: WB Saunders; 1998:514-5.

  42. Shim CS, Cheon YK, Cha SW. Prospective study of the effectiveness of percutaneous transhepatic photodynamic therapy for advanced bile duct cancer and the role of intraductal ultrasonography in response assessment. Endoscopy. May 2005;37(5):425-33.

  43. Vlahcevic ZR, Heuman DM. Diseases of the gallbladder and bile ducts. In: Goldman G, ed. Cecil Textbook of Medicine. 21 ed. Philadelphia: WB Saunders; 2000:821-33.

  44. Yeh TS, Chen NH, Jan YY, et al. Obstructive jaundice caused by biliary tuberculosis: spectrum of the diagnosis and management. Gastrointest Endosc. Jul 1999;50(1):105-8. [Medline].

  45. Yeh TS, Jan YY, Tseng JH. Malignant perihilar biliary obstruction: magnetic resonance cholangiopancreatographic findings. Am J Gastroenterol. Feb 2000;95(2):432-40.

 
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