History
In the absence of symptoms of the primary disease, most patients with bile duct strictures remain asymptomatic until the lumen of the bile duct is sufficiently narrowed to cause resistance to the flow of bile. Occasionally, patients may have intermittent episodes of right upper quadrant pain (biliary colic), with or without laboratory features of biliary obstruction. Patients most often present with features of obstructive jaundice. On occasion, a patient may present dramatically with sepsis and hypotension due to ascending cholangitis.
The clinical manifestations of obstructive jaundice may develop rapidly or slowly depending on the underlying cause. Patients may report right upper abdominal discomfort, pruritus, yellow discoloration of skin, and steatorrhea. With chronic cholestasis, xanthomas appear around the eyes, chest, back, and on extensor surfaces. Weight loss and deficiency of calcium and fat-soluble vitamins can occur. Patients also may report anorexia, nausea, vomiting, and cachexia. Insidious weight loss may suggest malignant obstruction.
Cholangitis occurs in the presence of partial or complete obstruction of the common bile duct (CBD), with increased intraluminal pressures, bacterial infection of the bile with multiplication of the organisms within the duct, and seeding of the bloodstream with bacteria or endotoxin. Cholangitis can rapidly become a life-threatening condition. Clinical presentation varies, with the Charcot triad of fever and chills, jaundice, and right upper quadrant abdominal pain occurring in most patients. A smaller proportion of those with cholangitis may also have altered mental status and hypotension (ie, Reynold pentad). In the absence of previous instrumentation, cholangitis is uncommon with malignant strictures.
The etiology of bile duct strictures is sometimes obvious at the time of presentation. In unclear cases, clues from the patient's history may help in making an accurate diagnosis. Most of the benign biliary strictures following injury during cholecystectomy go unrecognized at the time of surgery (in as many as 75% of cases). Presentation after more than 5 years may occur in 30% of cases; therefore, a history of recent or past cholecystectomy should be sought in all cases. Information about the postoperative period, especially excessive drainage from surgical wounds and drains and episodes of fever, jaundice, and abdominal distention, are important in patients presenting shortly after surgery.
A detailed history with emphasis on symptoms suggestive of pancreatitis, recurrent episodes of cholangitis, cholestatic disorders (eg, primary sclerosing cholangitis), hepatobiliary surgery, [9, 10, 11, 18, 12] trauma or radiation to the upper abdomen, [15, 16] alcohol abuse, intravenous drug use, or human immunodeficiency virus (HIV) infection [19, 20] should be obtained. This history provides valuable clues regarding the underlying disease and may prove useful in guiding management of patients with bile duct strictures.
Physical Examination
Asymptomatic patients with bile duct strictures may have unremarkable physical examination findings. Most patients with tight strictures have clinically apparent jaundice. Excoriations of the skin may be seen in patients with pruritus.
Patients presenting with cholangitis may also have fever and right upper quadrant tenderness in addition to jaundice (ie, Charcot triad), hypotension, and altered mental status (ie, Reynold pentad).
The presence of palmar erythema, Dupuytren contracture, gynecomastia, spider angiomas, ascites, and splenomegaly may suggest underlying cirrhosis and portal hypertension. A palpable, nontender gallbladder and jaundice are usually observed in patients with malignant obstruction. The presence of these symptoms is called the Courvoisier sign. An enlarged nodular liver may indicate malignancy involving the liver or a large right upper quadrant mass may indicate a malignancy involving the gallbladder. The presence of a friction rub or bruit may also suggest malignancy.
Patients with a major surgical injury to the bile duct and those with recurrent strictures and interventions may have evidence of a bile leak in the form of a biliary fistula, biliary peritonitis, or a biloma. These complications usually become evident early in the postoperative period but sometimes appear weeks to months later.
Attention should be given to the nutritional status of the patient. Features of fat-soluble vitamin deficiency may be present and should be sought.
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Endoscopic retrograde cholangiopancreatographic image of a cholangiocarcinoma at the bifurcation of the right and left hepatic ducts (Klatskin tumor).
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Endoscopic retrograde cholangiopancreatographic cholangiogram demonstrating a long bile duct stricture that represents external compression by gallbladder cancer.
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Transhepatic cholangiogram with an external drainage catheter in place.
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Endoscopic retrograde cholangiopancreatographic image of a cholangiogram in a patient with cholangiocarcinoma whose condition has been treated with a metal stent.
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Endoscopic retrograde cholangiopancreatographic cholangiogram of a solitary benign stricture of the distal bile duct. Resection demonstrated sclerosing cholangitis.
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Endoscopic retrograde cholangiopancreatographic cholangiogram demonstrating an isolated mid-hepatic duct stricture as a result of pancreatic cancer.
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Endoscopic retrograde cholangiopancreatographic cholangiogram demonstrating diffuse stricturing of the intrahepatic ducts that is consistent with primary sclerosing cholangitis.
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Periductal onion skin fibrosis seen in primary sclerosing cholangitis.
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Periductal lymphocytic and plasma cell infiltrate that is consistent with autoimmune cholangiopathy.
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Focal intrahepatic benign bile duct stricture after cholecystectomy.
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Multiple small bile duct stones seen on magnetic resonance cholangiopancreatography (MRCP).
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Irregular common bile duct stricture as a result of cholangiocarcinoma.
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This image is an example of an intraoperative cholangiogram performed during a laparoscopic cholecystectomy.
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Focal bile duct stricture as a result of pancreatic cancer in the head of the pancreas.
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Percutaneous transhepatic cholangiogram with balloon dilation of a postoperative bile duct stricture.
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Benign distal common bile duct stricture seen during a cholecystostomy injection in an elderly male. The stricture resolved with a 4-week course of oral corticosteroid therapy.
