Diagnostic Considerations

Patients presenting with acute ascending cholangitis should undergo urgent biliary drainage when an appropriate response to antibiotic therapy is not achieved or when the initial presentation is severe.

Other conditions to consider in patients with suspected bile duct strictures include the following:

Autoimmune cholangiopathy
Cholestasis associated with parenteral nutrition
Cholestasis associated with sepsis
Drug-induced cholestasis
Postoperative jaundice
Primary sclerosing cholangitis
Primary biliary cirrhosis

Differential Diagnoses

Gallstones (Cholelithiasis)

Workup

Vecchio R, Ferrara M, Pucci L, Meli G, Latteri S. [Treatment of iatrogenic lesions of the common bile duct] [Italian]. Minerva Chir. 1995 Jan-Feb. 50(1-2):29-38. [QxMD MEDLINE Link].
Hanau LH, Steigbigel NH. Acute (ascending) cholangitis. Infect Dis Clin North Am. 2000 Sep. 14(3):521-46. [QxMD MEDLINE Link].
Hastier P, Buckley JM, Peten EP, Dumas R, Delmont J. Long term treatment of biliary stricture due to chronic pancreatitis with a metallic stent. Am J Gastroenterol. 1999 Jul. 94(7):1947-8. [QxMD MEDLINE Link].
Deviere J, Cremer M, Baize M, Love J, Sugai B, Vandermeeren A. Management of common bile duct stricture caused by chronic pancreatitis with metal mesh self expandable stents. Gut. 1994 Jan. 35(1):122-6. [QxMD MEDLINE Link]. [Full Text].
Kamisawa T, Tu Y, Egawa N, et al. Involvement of pancreatic and bile ducts in autoimmune pancreatitis. World J Gastroenterol. 2006 Jan 28. 12(4):612-4. [QxMD MEDLINE Link]. [Full Text].
Singh A, Gelrud A, Agarwal B. Biliary strictures: diagnostic considerations and approach. Gastroenterol Rep (Oxf). 2015 Feb. 3(1):22-31. [QxMD MEDLINE Link]. [Full Text].
Lee HJ, Cho KB. Diagnosis of malignant biliary stricture: more is better. Clin Endosc. 2018 Mar. 51(2):115-7. [QxMD MEDLINE Link]. [Full Text].
Magistrelli P, Masetti R, Coppola R, et al. Changing attitudes in the palliation of proximal malignant biliary obstruction. J Surg Oncol Suppl. 1993. 3:151-3. [QxMD MEDLINE Link].
Klein AS, Savader S, Burdick JF, et al. Reduction of morbidity and mortality from biliary complications after liver transplantation. Hepatology. 1991 Nov. 14(5):818-23. [QxMD MEDLINE Link].
Orons PD, Sheng R, Zajko AB. Hepatic artery stenosis in liver transplant recipients: prevalence and cholangiographic appearance of associated biliary complications. AJR Am J Roentgenol. 1995 Nov. 165(5):1145-9. [QxMD MEDLINE Link]. [Full Text].
Mosca S, Militerno G, Guardascione MA, et al. Late biliary tract complications after orthotopic liver transplantation: diagnostic and therapeutic role of endoscopic retrograde cholangiopancreatography. J Gastroenterol Hepatol. 2000 Jun. 15(6):654-60. [QxMD MEDLINE Link].
Schwartz DA, Petersen BT, Poterucha JJ, Gostout CJ. Endoscopic therapy of anastomotic bile duct strictures occurring after liver transplantation. Gastrointest Endosc. 2000 Feb. 51(2):169-74. [QxMD MEDLINE Link].
Colonna JO 2nd, Shaked A, Gomes AS, et al. Biliary strictures complicating liver transplantation. Incidence, pathogenesis, management, and outcome. Ann Surg. 1992 Sep. 216(3):344-50; discussion 350-2. [QxMD MEDLINE Link]. [Full Text].
Sundaram V, Jones DT, Shah NH, et al. Posttransplant biliary complications in the pre- and post-model for end-stage liver disease era. Liver Transpl. 2011 Apr. 17(4):428-35. [QxMD MEDLINE Link].
Cherqui D, Palazzo L, Piedbois P, et al. Common bile duct stricture as a late complication of upper abdominal radiotherapy. J Hepatol. 1994 Jun. 20(6):693-7. [QxMD MEDLINE Link].
Nakakubo Y, Kondo S, Katoh H, Shimizu M. Biliary stricture as a possible late complication of radiation therapy. Hepatogastroenterology. 2000 Nov-Dec. 47(36):1531-2. [QxMD MEDLINE Link].
Fan ST, Ng IO, Choi TK, Lai EC. Tuberculosis of the bile duct: a rare cause of biliary stricture. Am J Gastroenterol. 1989 Apr. 84(4):413-4. [QxMD MEDLINE Link].
Pozsar J, Sahin P, Laszlo F, Topa L. Endoscopic treatment of sphincterotomy-associated distal common bile duct strictures by using sequential insertion of multiple plastic stents. Gastrointest Endosc. 2005 Jul. 62(1):85-91. [QxMD MEDLINE Link].
Cello JP. Human immunodeficiency virus-associated biliary tract disease. Semin Liver Dis. 1992 May. 12(2):213-8. [QxMD MEDLINE Link].
Nash JA, Cohen SA. Gallbladder and biliary tract disease in AIDS. Gastroenterol Clin North Am. 1997 Jun. 26(2):323-35. [QxMD MEDLINE Link].
Patel AH, Harnois DM, Klee GG, LaRusso NF, Gores GJ. The utility of CA 19-9 in the diagnoses of cholangiocarcinoma in patients without primary sclerosing cholangitis. Am J Gastroenterol. 2000 Jan. 95(1):204-7. [QxMD MEDLINE Link].
Lempinen M, Isoniemi H, Makisalo H, et al. Enhanced detection of cholangiocarcinoma with serum trypsinogen-2 in patients with severe bile duct strictures. J Hepatol. 2007 Nov. 47(5):677-83. [QxMD MEDLINE Link].
Stavropoulos S, Larghi A, Verna E, Battezzati P, Stevens P. Intraductal ultrasound for the evaluation of patients with biliary strictures and no abdominal mass on computed tomography. Endoscopy. 2005 Aug. 37(8):715-21. [QxMD MEDLINE Link].
Nandalur KR, Hussain HK, Weadock WJ, et al. Possible biliary disease: diagnostic performance of high-spatial-resolution isotropic 3D T2-weighted MRCP. Radiology. 2008 Dec. 249(3):883-90. [QxMD MEDLINE Link].
Mansfield JC, Griffin SM, Wadehra V, Matthewson K. A prospective evaluation of cytology from biliary strictures. Gut. 1997 May. 40(5):671-7. [QxMD MEDLINE Link]. [Full Text].
Kipp BR, Stadheim LM, Halling SA, et al. A comparison of routine cytology and fluorescence in situ hybridization for the detection of malignant bile duct strictures. Am J Gastroenterol. 2004 Sep. 99(9):1675-81. [QxMD MEDLINE Link].
Cote GA, Slivka A, Tarnasky P, et al. Effect of covered metallic stents compared with plastic stents on benign biliary stricture resolution: A randomized clinical trial. JAMA. 2016 Mar 22-29. 315(12):1250-7. [QxMD MEDLINE Link]. [Full Text].
Tal AO, Finkelmeier F, Filmann N, et al. Multiple plastic stents versus covered metal stent for treatment of anastomotic biliary strictures after liver transplantation: a prospective, randomized, multicenter trial. Gastrointest Endosc. 2017 Dec. 86(6):1038-45. [QxMD MEDLINE Link].
Gong Y, Huang ZB, Christensen E, Gluud C. Ursodeoxycholic acid for primary biliary cirrhosis. Cochrane Database Syst Rev. 2008 Jul 16. CD000551. [QxMD MEDLINE Link]. [Full Text].
Mahid SS, Jafri NS, Brangers BC, et al. Meta-analysis of cholecystectomy in symptomatic patients with positive hepatobiliary iminodiacetic acid scan results without gallstones. Arch Surg. 2009 Feb. 144(2):180-7. [QxMD MEDLINE Link].
Olsen JC, McGrath NA, Schwarz DG, Cutcliffe BJ, Stern JL. A double-blind randomized clinical trial evaluating the analgesic efficacy of ketorolac versus butorphanol for patients with suspected biliary colic in the emergency department. Acad Emerg Med. 2008 Aug. 15(8):718-22. [QxMD MEDLINE Link].
Bismuth H, Nakache R, Diamond T. Management strategies in resection for hilar cholangiocarcinoma. Ann Surg. 1992 Jan. 215(1):31-8. [QxMD MEDLINE Link]. [Full Text].
Bjornsson E, Lindqvist-Ottosson J, Asztely M, Olsson R. Dominant strictures in patients with primary sclerosing cholangitis. Am J Gastroenterol. 2004 Mar. 99(3):502-8. [QxMD MEDLINE Link].
Yoon WJ, Brugge WR. Endoscopic evaluation of bile duct strictures. Gastrointest Endosc Clin N Am. 2013 Apr. 23(2):277-93. [QxMD MEDLINE Link].
Bueno JT, Gerdes H, Kurtz RC. Endoscopic management of occluded biliary Wallstents: a cancer center experience. Gastrointest Endosc. 2003 Dec. 58(6):879-84. [QxMD MEDLINE Link].
Frattaroli FM, Reggio D, Guadalaxara A, Illomei G, Pappalardo G. Benign biliary strictures: a review of 21 years of experience. J Am Coll Surg. 1996 Nov. 183(5):506-13. [QxMD MEDLINE Link].
Gibbons JC, Williams SJ. Progress in the endoscopic management of benign biliary strictures. J Gastroenterol Hepatol. 1998 Feb. 13(2):116-24. [QxMD MEDLINE Link].
Ishizuka D, Shirai Y, Hatakeyama K. Ischemic biliary stricture due to lymph node dissection in the hepatoduodenal ligament. Hepatogastroenterology. 1998 Nov-Dec. 45(24):2048-50. [QxMD MEDLINE Link].
Itani KM, Taylor TV. The challenge of therapy for pancreatitis-related common bile duct stricture. Am J Surg. 1995 Dec. 170(6):543-6. [QxMD MEDLINE Link].
Kadir S, White RI Jr. Biliary stricture dilatation: multicenter review of clinical management in 73 patients. Radiology. 1987 Jan. 162(1 pt 1):286. [QxMD MEDLINE Link]. [Full Text].
Kim KH, Sung CK, Park BG, et al. Clinical significance of intrahepatic biliary stricture in efficacy of hepatic resection for intrahepatic stones. J Hepatobiliary Pancreat Surg. 1998. 5(3):303-8. [QxMD MEDLINE Link].
Levy MJ, Baron TH, Clayton AC, et al. Prospective evaluation of advanced molecular markers and imaging techniques in patients with indeterminate bile duct strictures. Am J Gastroenterol. 2008 May. 103(5):1263-73. [QxMD MEDLINE Link].
Lipsett PA, Pitt HA, Colombani PM, Boitnott JK, Cameron JL. Choledochal cyst disease. A changing pattern of presentation. Ann Surg. 1994 Nov. 220(5):644-52. [QxMD MEDLINE Link]. [Full Text].
Lombard M, Farrant M, Karani J, Westaby D, Williams R. Improving biliary-enteric drainage in primary sclerosing cholangitis: experience with endoscopic methods. Gut. 1991 Nov. 32(11):1364-8. [QxMD MEDLINE Link]. [Full Text].
Maier M, Kohler B, Benz C, Korber H, Riemann JF. [Percutaneous transhepatic cholangioscopy (PTCS)--an important supplement in diagnosis and therapy of biliary tract diseases (indications, technique and results)] [German]. Z Gastroenterol. 1995 Aug. 33(8):435-9. [QxMD MEDLINE Link].
McDonald ML, Farnell MB, Nagorney DM, Ilstrup DM, Kutch JM. Benign biliary strictures: repair and outcome with a contemporary approach. Surgery. 1995 Oct. 118(4):582-90; discussion 590-1. [QxMD MEDLINE Link].
Mendler MH, Bouillet P, Sautereau D, et al. Value of MR cholangiography in the diagnosis of obstructive diseases of the biliary tree: a study of 58 cases. Am J Gastroenterol. 1998 Dec. 93(12):2482-90. [QxMD MEDLINE Link].
Moore AV Jr, Illescas FF, Mills SR, et al. Percutaneous dilation of benign biliary strictures. Radiology. 1987 Jun. 163(3):625-8. [QxMD MEDLINE Link]. [Full Text].
Morrison MC, Lee MJ, Saini S, Brink JA, Mueller PR. Percutaneous balloon dilatation of benign biliary strictures. Radiol Clin North Am. 1990 Nov. 28(6):1191-201. [QxMD MEDLINE Link].
Nealon WH, Urrutia F. Long-term follow-up after bilioenteric anastomosis for benign bile duct stricture. Ann Surg. 1996 Jun. 223(6):639-45; discussion 645-8. [QxMD MEDLINE Link]. [Full Text].
Pereira-Lima JC, Jakobs R, Maier M, et al. Endoscopic biliary stenting for the palliation of pancreatic cancer: results, survival predictive factors, and comparison of 10-French with 11.5-French gauge stents. Am J Gastroenterol. 1996 Oct. 91(10):2179-84. [QxMD MEDLINE Link].
Rosch T, Hofrichter K, Frimberger E, et al. ERCP or EUS for tissue diagnosis of biliary strictures? A prospective comparative study. Gastrointest Endosc. 2004 Sep. 60(3):390-6. [QxMD MEDLINE Link].
Roslyn JJ, Binns GS, Hughes EF. Open cholecystectomy. A contemporary analysis of 42,474 patients. Ann Surg. 1993 Aug. 218(2):129-37. [QxMD MEDLINE Link].
Shah RJ, Langer DA, Antillon MR, Chen YK. Cholangioscopy and cholangioscopic forceps biopsy in patients with indeterminate pancreaticobiliary pathology. Clin Gastroenterol Hepatol. 2006 Feb. 4(2):219-25. [QxMD MEDLINE Link].
Smits ME, Rauws EA, van Gulik TM, et al. Long-term results of endoscopic stenting and surgical drainage for biliary stricture due to chronic pancreatitis. Br J Surg. 1996 Jun. 83(6):764-8. [QxMD MEDLINE Link].
Tenner S, Roston A, Lichtenstein D, et al. Eosinophilic cholangiopathy. Gastrointest Endosc. 1997 Mar. 45(3):307-9. [QxMD MEDLINE Link].
Tocchi A, Mazzoni G, Liotta G, et al. Management of benign biliary strictures: biliary enteric anastomosis vs endoscopic stenting. Arch Surg. 2000 Feb. 135(2):153-7. [QxMD MEDLINE Link]. [Full Text].
Vitale GC, George M, McIntyre K. Endoscopic management of benign and malignant biliary strictures. Am J Surg. 1996 Jun. 171(6):553-7. [QxMD MEDLINE Link].
Vitale GC, Larson GM, George M, Tatum C. Management of malignant biliary stricture with self-expanding metallic stent. Surg Endosc. 1996 Oct. 10(10):970-3. [QxMD MEDLINE Link].
Ogura T, Takenaka M, Shiomi H, et al. Long-term outcomes of EUS-guided transluminal stent deployment for benign biliary disease: Multicenter clinical experience (with videos). Endosc Ultrasound. 2019 Sep 25. [QxMD MEDLINE Link].
Pereira P, Morais R, Vilas-Boas F, et al. Brush cytology performance for the assessment of biliopancreatic strictures. Acta Cytol. 2019 Sep 24. 1-8. [QxMD MEDLINE Link].

Media Gallery

Endoscopic retrograde cholangiopancreatographic image of a cholangiocarcinoma at the bifurcation of the right and left hepatic ducts (Klatskin tumor).
Endoscopic retrograde cholangiopancreatographic cholangiogram demonstrating a long bile duct stricture that represents external compression by gallbladder cancer.
Transhepatic cholangiogram with an external drainage catheter in place.
Endoscopic retrograde cholangiopancreatographic image of a cholangiogram in a patient with cholangiocarcinoma whose condition has been treated with a metal stent.
Endoscopic retrograde cholangiopancreatographic cholangiogram of a solitary benign stricture of the distal bile duct. Resection demonstrated sclerosing cholangitis.
Endoscopic retrograde cholangiopancreatographic cholangiogram demonstrating an isolated mid-hepatic duct stricture as a result of pancreatic cancer.
Endoscopic retrograde cholangiopancreatographic cholangiogram demonstrating diffuse stricturing of the intrahepatic ducts that is consistent with primary sclerosing cholangitis.
Periductal onion skin fibrosis seen in primary sclerosing cholangitis.
Periductal lymphocytic and plasma cell infiltrate that is consistent with autoimmune cholangiopathy.
Focal intrahepatic benign bile duct stricture after cholecystectomy.
Multiple small bile duct stones seen on magnetic resonance cholangiopancreatography (MRCP).
Irregular common bile duct stricture as a result of cholangiocarcinoma.
This image is an example of an intraoperative cholangiogram performed during a laparoscopic cholecystectomy.
Focal bile duct stricture as a result of pancreatic cancer in the head of the pancreas.
Percutaneous transhepatic cholangiogram with balloon dilation of a postoperative bile duct stricture.
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.

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Author

William R Brugge, MD Professor of Medicine, Harvard Medical School; Director, Gastrointestinal Endoscopy Unit, Massachusetts General Hospital

William R Brugge, MD is a member of the following medical societies: American College of Gastroenterology, American College of Physicians, American Gastroenterological Association, American Pancreatic Association, American Society for Gastrointestinal Endoscopy, Crohn's and Colitis Foundation of America, American Federation for Clinical Research

Disclosure: Received grant/research funds from RedPath for consulting.

Coauthor(s)

Ashraf Saleemuddin, MD Attending Gastroenterologist

Ashraf Saleemuddin, MD is a member of the following medical societies: American College of Gastroenterology

Disclosure: Nothing to disclose.

Parviz Nikoomanesh, MD †

Parviz Nikoomanesh, MD is a member of the following medical societies: American College of Gastroenterology, American College of Physicians, American Gastroenterological Association, American Society for Gastrointestinal Endoscopy

Disclosure: Nothing to disclose.

Lawrence J Cheskin, MD Director, Johns Hopkins Weight Management Center; Associate Professor, Health, Behavior & Society, Johns Hopkins Bloomberg School of Public Health; Joint Appointment, Department of Medicine, Division of Gastroenterology, Johns Hopkins University School of Medicine; International Health/Human Nutrition, JH Bloomberg School of Public Health

Lawrence J Cheskin, MD is a member of the following medical societies: American College of Gastroenterology, American College of Physicians, American Gastroenterological Association

Disclosure: Received consulting fee from Medifast for board membership; Received none from Vivus for purchase of stock as an investment; Received none from Medifast for purchase of stock as an investment.

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

Praveen K Roy, MD, MSc Clinical Assistant Professor of Medicine, University of New Mexico School of Medicine

Praveen K Roy, MD, MSc is a member of the following medical societies: Alaska State Medical Association, American Gastroenterological Association

Disclosure: Nothing to disclose.

Additional Contributors

David Greenwald, MD Professor of Clinical Medicine, Fellowship Program Director, Department of Medicine, Division of Gastroenterology, Montefiore Medical Center, Albert Einstein College of Medicine

David Greenwald, MD is a member of the following medical societies: Alpha Omega Alpha, New York Society for Gastrointestinal Endoscopy, American College of Gastroenterology, American College of Physicians, American Gastroenterological Association, American Society for Gastrointestinal Endoscopy

Disclosure: Nothing to disclose.

Acknowledgements

Hemant Pande, MD Consulting Staff, Department of Gastroenterology, Leesville Surgical Clinic and Digestive Disease Center

Hemant Pande, MD is a member of the following medical societies: American College of Gastroenterology, American Gastroenterological Association, and American Society for Gastrointestinal Endoscopy

Disclosure: Nothing to disclose.