eMedicine Specialties > Gastroenterology > Biliary

Biliary Obstruction: Treatment & Medication

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

Treatment

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 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 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. 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.

Consultations

  • Gastroenterologist
  • Radiologist
  • General surgeon

Diet

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.

Activity

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

Medication

Bile acid – binding resins and ursodeoxycholic acid are used to treat cholelithiasis when surgery is refused or is inappropriate. Normal gallbladder function must be established by oral cholecystography findings prior to the initiation of drug therapy.

Gallstone solubilizing agents

Ursodeoxycholic acid (ursodiol) is a naturally occurring bile acid present in small quantities in human bile. Suppresses liver synthesis and secretion of cholesterol. Inhibits intestinal cholesterol absorption.


Ursodiol (Actigall)

Used to treat biliary stasis and dissolve gallstones.

Adult

8-10 mg/kg/d PO divided bid/tid pc until 3 mo after stone is dissolved

Pediatric

10-15 mg/kg/d PO divided tid pc

Decreased effect/absorption with aluminum-containing antacids and bile acid–binding resins; estrogens or oral contraceptives may antagonize effect by promoting gallstone formation

Documented hypersensitivity; calcified cholesterol, radiopaque or radiolucent bile pigment stones

Pregnancy

B - Usually safe but benefits must outweigh the risks.

Precautions

Transaminases (ie, AST, ALT) should be monitored periodically for hepatotoxicity; may cause adverse GI effects, perform US imaging every 6 mo for 1 y to monitor effect, effectiveness dependent on gallstone size/composition, effect unlikely if gallstones are not partially dissolved after 1 y

Narcotic antagonists

Endogenous opioids may effect pruritic development associated with cholestasis. Treatment with narcotic antagonists may attenuate pruritus.


Naloxone (Narcan)

Prevents or reverses opioid effects (eg, hypotension, respiratory depression, sedation, pruritus), possibly by displacing opiates from their receptors.

Adult

0.4 mg IV initially, followed by 0.2 mcg/kg/min

Pediatric

Not established

Decreased effects of captopril, clonidine, and opioid analgesia

Pregnancy

B - Usually safe but benefits must outweigh the risks.

Precautions

Caution in cardiovascular disease and impaired liver or kidney function; may precipitate withdrawal symptoms in patients dependent on opiates

Antibiotics

Rifampin, in particular, has been suggested as a treatment for cholestasis in certain patients. By reducing intestinal flora, it slows conversion of primary to more toxic secondary bile salts. Has also been shown to decrease serum levels of bilirubin and ALP, perhaps in part contributing to its effectiveness in minimizing associated pruritus.


Rifampin (Rifadin, Rifadin IV, Rimactane)

Inhibits DNA-dependent bacterial by binding to the beta subunit of DNA-dependent RNA polymerase, blocking RNA transcription.

Adult

5-17 mg/kg/d PO/IV qd; not to exceed 600 mg/d

Pediatric

Not established

Induces microsomal enzymes, which may decrease effects of acetaminophen, PO anticoagulants, barbiturates, benzodiazepines, beta-blockers, chloramphenicol, PO contraceptives, corticosteroids, mexiletine, cyclosporine, digitoxin, disopyramide, estrogens, hydantoins, methadone, clofibrate, quinidine, dapsone, tazobactam, sulfonylureas, theophyllines, tocainide, and digoxin; BP may increase with coadministration of enalapril; coadministration with isoniazid may result in higher rate of hepatotoxicity than with either agent alone (discontinue one or both agents if alterations in LFTs occur)

Pregnancy

C - Safety for use during pregnancy has not been established.

Precautions

Heartburn, epigastric distress, anorexia, nausea, vomiting, jaundice, flatulence, cramps, and diarrhea may occur; pseudomembranous colitis has been reported; thrombocytopenia, headache, fever, drowsiness, fatigue, ataxia, dizziness, inability to concentrate, mental confusion, behavioral changes, muscular weakness, pain in extremities, and generalized numbness have been observed
Rarely, hemolysis, hemoglobinuria, hematuria, interstitial nephritis, acute tubular necrosis, renal insufficiency, and acute renal failure have occurred; liver dysfunction may occur and, thus, patients with impaired liver function or taking other hepatotoxic drugs concomitantly should be given rifampin only in cases of necessity and then with caution and under strict medical supervision; in these patients, carefully monitor liver function prior to therapy and then every 2-4 wk during therapy; if signs of hepatocellular damage occur, withdraw; has enzyme induction properties that can enhance the metabolism of endogenous and exogenous substrates, including adrenal hormones, thyroid hormones, vitamin D, and PO hormonal/contraceptive therapy; diabetes may become more difficult to control; may produce a reddish coloration of the urine, sweat, sputum, and tears; soft contact lenses may be permanently stained

Bile acid–binding resins

Inhibit enterohepatic reuptake of intestinal bile salts.


Cholestyramine (Questran)

Acts as a cholesterol-lowering agent. Forms a nonabsorbable complex with bile acids in the intestine, which inhibits enterohepatic reuptake of intestinal bile salts.

Adult

4-6 g PO tid ac (4 g resin/packet or level scoopful); alternatively, 8-12 g PO with breakfast and 4-6 g PO with lunch; not to exceed 24 g/d

Pediatric

240 mg/kg/d PO divided tid ac; not to exceed 8 g/d

Inhibits absorption of numerous drugs (eg, amiodarone, digoxin, fat-soluble vitamins, folic acid, hydrocortisone, niacin, HMG-CoA inhibitors, thyroid, PO antidiabetic agents, ursodiol, phenobarbital, phosphates, valproate); separating doses by 2-4 h may minimize interaction if drug does not undergo enterohepatic recirculation; monitor serum levels and adjust doses accordingly

Documented hypersensitivity; complete biliary obstruction

Pregnancy

C - Safety for use during pregnancy has not been established.

Precautions

Mix powder with water, juice, or milk; discontinue cautiously with concurrent drugs, adjust doses accordingly; causes constipation, heartburn, nausea, and vomiting; caution in PKU when aspartame-containing product is used


Colestipol (Colestid)

Binds bile acids in the intestine, facilitates partial removal of bile acids from enterohepatic circulation, and prevents their reabsorption.

Adult

2-g tab PO qd/bid initially, increase dose by 2 g q1-2mo; not to exceed 16 g/d

Pediatric

Not established

Inhibits absorption of numerous drugs (eg, amiodarone, digoxin, fat-soluble vitamins, folic acid, hydrocortisone, niacin, HMG-CoA inhibitors, thyroid, PO antidiabetic agents, ursodiol, phenobarbital, phosphates, valproate); separating doses by 2-4 h may minimize interaction if drug does not undergo enterohepatic recirculation; monitor serum levels and adjust doses accordingly; conflicting result with digoxin, colestipol preferred over cholestyramine for patients taking digoxin

Documented hypersensitivity; complete biliary obstruction

Pregnancy

B - Usually safe but benefits must outweigh the risks.

Precautions

Swallow tabs whole (ie, do not crush, cut, or chew) one at a time with water; discontinue cautiously with concurrent drugs, adjust doses accordingly; may cause GI obstruction, constipation, or nausea

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

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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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