Medscape is available in 5 Language Editions – Choose your Edition here.


Biliary Obstruction Treatment & Management

  • Author: Jennifer Lynn Bonheur, MD; Chief Editor: Julian Katz, MD  more...
Updated: Mar 11, 2015

Medical Care

Treatment of the underlying cause is the objective of the medical treatment of biliary obstruction. Do not subject patients to surgery until the diagnosis is clear. Thus, make every effort to visualize the biliary tree in patients who are jaundiced, with appropriate use of noninvasive and invasive techniques. Importantly, however, a delay in moving on to more invasive therapeutic modalities in a patient who does not initially respond to medical and supportive care increases the risks of an adverse outcome (see Workup).

  • In cases of cholelithiasis in which either the patient refuses surgery or surgical intervention is not appropriate, an attempt to dissolve noncalcified calculi may occasionally be made by the administration of oral bile salts for as long as 2 years.
    • Because gallbladder emptying is an important determinant of stone clearance, normal gallbladder function must first be established via oral cholecystography.
    • Ursodeoxycholic acid (10 mg/kg/d) works to reduce biliary secretion of cholesterol. In turn, this decreases the cholesterol saturation of bile. In 30-40% of patients, this results in the gradual dissolution of cholesterol-containing stones. However, stones may recur within 5 years once the drug is stopped (50% of patients).
    • Extracorporeal shock-wave lithotripsy may be used as an adjunct to oral dissolution therapy. By increasing the surface-to-volume ratio of the stones, it both enhances dissolution of stones and makes clearing the smaller fragments easier. Contraindications include complications of gallstone disease (eg, cholecystitis, choledocholelithiasis, biliary pancreatitis), pregnancy, and coagulopathy or anticoagulant medications (ie, because of the risk of hematoma formation). Lithotripsy is associated with a 70% recurrence rate for gallstones, is not approved by the US Food and Drug Association, and is restricted to investigational programs only.
  • Bile acid–binding resins, cholestyramine (4 g) or colestipol (5 g), dissolved in water or juice 3 times a day may be useful in the symptomatic treatment of pruritus associated with biliary obstruction. However, deficiencies of vitamins A, D, E, and K may occur if steatorrhea is present and can be aggravated by the use of cholestyramine or colestipol. Therefore, include an individualized regimen for replacement of these vitamins as needed in the patient's treatment.
  • Antihistamines may be used for the symptomatic treatment of pruritus, particularly as a sedative at night. Their effectiveness is modest. Endogenous opioids have been suggested as possibly playing a role in the development of pruritus of cholestasis. Treatment with parentally administered naloxone and, more recently, nalmefene, has improved pruritus in some patients.
  • Rifampin has been suggested as a medical adjunct to the treatment of cholestasis. By decreasing the intestinal flora, it slows the conversion of primary to secondary bile salts and may reduce serum bilirubin levels, ALP levels, and pruritus in certain patients.
  • Discontinuation of medications that may be causing or exacerbating cholestasis and/or biliary obstruction often leads to full recovery. Similarly, appropriate treatment of infections (eg, viral, bacterial, parasitic) is indicated.

Surgical Care

As with medical care, the need for surgical intervention depends on the cause of biliary obstruction.

  • Cholecystectomy is the recommended treatment in cases of symptomatic cholelithiasis because these patients have an increased risk of developing complications.
    • Open cholecystectomy is relatively safe, with a mortality rate of 0.1-0.5 %.
    • Laparoscopic cholecystectomy remains the treatment of choice for symptomatic gallstones, partially because of the shorter recovery period (return to work in an average of 7 d), decreased postoperative discomfort, and improved cosmetic result.
    • Approximately 5% of laparoscopic cases are converted to an open procedure secondary to difficulty in visualizing the anatomy or a complication.
  • Resectability of neoplastic causes of biliary obstruction varies with respect to the location and extent of the disease. Photodynamic therapy (PDT) has been shown to have good results in the palliative treatment of advanced biliary tract malignancies, particularly when used in conjunction with a biliary stenting procedure.[12, 13] PDT produces localized tissue necrosis by applying a photosensitizing agent, which preferentially accumulates in the tumor tissue, and then exposing the area to laser light, which activates the medication and results in destruction of tumor cells.
  • Liver transplantation may be considered in appropriate patients.


See the list below:

  • Gastroenterologist
  • Radiologist
  • General surgeon


Obesity, excess energy intake, and rapid weight loss can lead to stone formation, with potential biliary obstruction as a consequence. Gradual and modest weight reduction may be of value in patients who are at risk.

  • Reduce intake of saturated fats.
  • High intake of fiber has been linked to a lower risk for gallstones.
  • Reduce intake of sugar because a high intake of sugar may be associated with an increased risk of gallstones.


Regular exercise may reduce the risk of gallstones and gallstone complications.

Contributor Information and Disclosures

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 Society for Gastrointestinal Endoscopy, New York Academy of Sciences, Sigma Xi

Disclosure: Nothing to disclose.


Peter F Ells, MD Associate Professor, Division of Gastroenterology-Hepatology, Albany Medical Center

Disclosure: Nothing to disclose.

Specialty Editor Board

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

Disclosure: Received salary from Medscape for employment. for: Medscape.

BS Anand, MD Professor, Department of Internal Medicine, Division of Gastroenterology, Baylor College of Medicine

BS Anand, MD is a member of the following medical societies: American Association for the Study of Liver Diseases, American College of Gastroenterology, American Gastroenterological Association, American Society for Gastrointestinal Endoscopy

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, Physicians for Social Responsibility

Disclosure: Nothing to disclose.

Additional Contributors

Anil Minocha, MD, FACP, FACG, AGAF, CPNSS 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, AGAF, CPNSS is a member of the following medical societies: American Academy of Clinical Toxicology, American Society for Gastrointestinal Endoscopy, American Federation for Clinical Research, American Association for the Study of Liver Diseases, American College of Forensic Examiners Institute, American College of Gastroenterology, American College of Physicians, American Gastroenterological Association

Disclosure: Nothing to disclose.


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

  1. Center SA. Diseases of the gallbladder and biliary tree. Vet Clin North Am Small Anim Pract. 2009 May. 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. 2009 Apr 16. epub ahead of print. [Medline].

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

  4. 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. 2008 Jun 16. [Medline].

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

  6. 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. 2009 May-Jun. 56(91-92):615-8. [Medline].

  7. 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. 2011 Nov 24. 59(117):[Medline].

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

  9. 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. 2009 Jun. 41(6):532-8. [Medline].

  10. Dhir V, Itoi T, Khashab MA, et al. Multicenter comparative evaluation of endoscopic placement of expandable metal stents for malignant distal common bile duct obstruction by ERCP or EUS-guided approach. Gastrointest Endosc. 2014 Dec 4. [Medline].

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

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

  13. 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. 2011 Nov. 197(5):W942-7. [Medline].

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

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

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

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

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

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

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

  21. 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. 1998 Sep. 93(9):1510-7. [Medline].

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

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

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

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

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

  27. Kaplan LM, Isselbacher KJ. Jaundice. 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.

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

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

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

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

  32. 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. 2001 Jul. 220(1):90-6. [Medline].

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

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

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

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

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

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

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

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

  41. 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. 2001 Oct. 96(10):2900-4. [Medline].

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

  43. 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. 2005 May. 37(5):425-33.

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

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

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

All material on this website is protected by copyright, Copyright © 1994-2016 by WebMD LLC. This website also contains material copyrighted by 3rd parties.