Bile Duct Strictures Treatment & Management

Updated: Oct 16, 2019
  • Author: William R Brugge, MD; Chief Editor: Praveen K Roy, MD, AGAF  more...
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Treatment

Approach Considerations

Patients with bile duct strictures who develop obstructive jaundice complicated by fever, infection, or duodenal obstruction are often admitted for urgent inpatient treatment of obstruction and/or infection.

Patients presenting with ascending cholangitis may need to be admitted to the intensive care unit, especially if they have altered mental status and hypotension. These patients should be started on broad-spectrum antibiotics with good gram-negative and anaerobic coverage.

In addition, urgent drainage and decompression of the biliary tree may be required when an appropriate response to antibiotic therapy is not achieved.

Patients with bile duct strictures amenable to endoscopic therapy can be treated in an inpatient or outpatient setting. Those requiring surgery generally have a longer hospital stay, especially in the postoperative period.

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Medical Care

Medical treatment consists of managing complications of bile duct strictures until definitive therapy can be instituted. Most patients who present with cholangitis have a response to antibiotics and supportive management. Patients who are elderly and frail and those presenting with hypotension or altered mental status are best treated in an intensive care unit.

The common organisms that cause cholangitis are Escherichia coli and Klebsiella, Enterococcus, Proteus, Bacteroides, and Clostridium species. Empiric antibiotic therapy should be effective against these organisms.

Traditionally, a combination of a penicillin, aminoglycoside (gentamicin), and metronidazole has been the preferred regimen. Newer penicillins, such as piperacillin/tazobactam or imipenem/cilastatin, also have excellent activity against anaerobes, enterococci, and gram-negative cocci.

Approximately 70-80% of patients respond to medical therapy and do not need urgent intervention. Patients not having a response to empiric antibiotic therapy within 24 hours or those with hypotension requiring vasopressors, disseminated intravascular coagulation, or multiorgan failure should be considered for immediate biliary decompression, which can be performed surgically, percutaneously, or endoscopically. Endoscopic or percutaneous decompression is often associated with lower morbidity and should be considered first.

There is no special diet and no restriction on physical activity is required for patients with bile duct strictures.

Consultations

Obtain consultations with the following specialists:

  • Gastroenterologist

  • Surgeon

  • Infectious disease specialist

  • Interventional radiologist

  • Oncologist

Transfer

As noted above, management of bile duct strictures is a complex problem requiring a multidisciplinary approach. The patient should be in a specialized center where expertise in diagnostic and therapeutic ERCP and biliary interventional radiology is available. Surgical therapy should also be performed in centers with staff experienced in performing hepatobiliary and pancreatic surgery.

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Surgical Care

Patients with cholangitis whose condition fail to improve with conservative treatment usually require urgent decompression of the obstructed biliary system. Treatment options for bile duct strictures include (1) endoscopic or percutaneous balloon dilatation and insertion of an endoprosthesis or (2) surgery.

Decompression of the biliary system

Decompression is usually performed endoscopically, with placement of a nasobiliary tube or stent after sphincterotomy.

Alternatives to endoscopic retrograde cholangiopancreatography (ERCP) are percutaneous transhepatic biliary drainage and surgical decompression. However, operative biliary decompression is associated with much higher morbidity and mortality compared with endoscopic therapy.

Endoscopic management

Benign biliary strictures (eg, postcholecystectomy, after liver transplantation) can be treated effectively with endoscopic therapy, which achieves a symptomatic and biochemical response in most cases.

Studies have shown that the long-term success rate of endoscopic stenting is comparable to that of surgery, with similar recurrence rates. Therefore, surgery should probably be reserved for those patients with complete ductal obstruction and for those in whom endoscopic therapy has failed.

Endoscopic therapy generally involves a sphincterotomy, which is performed at the first endoscopic session simultaneously with the placement of one or two 10F-12F stents across the area of obstruction. Dilatation of the stricture may be necessary if the stricture is too tight.

The insertion of a second stent may be possible only during a second endoscopy session. Thereafter, elective replacement of the stents seems desirable to prevent cholangitis secondary to stent occlusion because polyethylene stents generally clog in 3-4 months.

Sphincterotomy and endoscopic balloon dilatation

The combination of sphincterotomy and endoscopic balloon dilatation alone is not a reliable method of treating benign strictures.

Percutaneous treatment by balloon dilatation followed by short- to intermediate-term stent placement appears to provide a more durable result.

Endoscopic biliary stenting

This procedure is an alternative to surgery for the initial treatment of jaundice and cholangitis in patients with bile duct strictures due to chronic pancreatitis.

The morbidity and mortality rates associated with biliary stent insertion are low. Endoscopic therapy appears to be effective in this situation; however, the efficacy of this treatment in the long-term management of bile duct strictures from pancreatitis is limited by frequent stent blockages and migration and should be considered an alternative to surgery only in high-risk surgical candidates.

The role of metallic stents in this situation needs further evaluation. Opinions vary considerably regarding the clinical significance of bile duct strictures secondary to pancreatitis in asymptomatic patients and the appropriate treatment of these lesions. The low incidence of cholangitis and secondary biliary cirrhosis in association with asymptomatic bile duct strictures may justify a less aggressive approach.

In a multicenter, open-label, parallel, randomized clinical trial involving patients with treatment-naive, benign biliary strictures (N=112), investigators found evidence that fully covered, self-expandable metallic stents (cSEMS) are not inferior to multiple plastic stents in achieving biliary stricture resolution after 12 months. The cSEMS stricture resolution rate after no more than 12 months of endoscopic therapy was 50 of 54 patients (92.6%), compared with 41 of 48 patients (85.4%) for plastic stents. Furthermore, the mean number of endoscopic retrograde cholangiopancreatography procedures (ERCPs) to achieve stricture resolution was lower for cSEMS than for plastic stents. [27]

In an open-label, multicenter, randomized trial involving patients with confirmed anastomotic biliary strictures (ABSs), Tal et al found that patients who were treated with covered self-expandable metallic stents (cSEMS) required fewer endoscopic interventions for achieving similar efficacy as patients who were treated with multiple plastic stents (MPS). The initial treatment success rate was 95.8% (23/24) in the MPS group and 100% (24/24) in the cSEMSs group. [28]

Endoscopic therapy for PSC

Endoscopic therapy of primary sclerosing cholangitis (PSC) is palliative. The main goal is to improve pruritus and relieve jaundice before transplantation.

The treatment involves balloon dilatation of strictures, stone removal, and placement of plastic stents.

Endoscopic stent therapy is a safe and effective treatment modality for an acute exacerbation of disease caused by dominant extrahepatic bile duct strictures in patients with PSC. Stent therapy is generally not effective for multiple intrahepatic ductal strictures.

In carefully selected patients with PSC who do not have cirrhosis, resection and long-term stenting remain good options. Patients with cirrhosis should undergo liver transplantation.

The role of endoscopy in the treatment of secondary biliary stricture associated with conditions such as HIV infection remains undefined. These patients have advanced acquired immunodeficiency syndrome (AIDS); however, AIDS-related cholangitis per se rarely causes death. ERCP and sphincterotomy may help to relieve an individual patient's pain and improve the quality of life.

Endoscopic therapy for malignant strictures

The treatment of malignant bile duct strictures requires consideration of a number of factors, the most important being the extremely low survival and cure rates associated with the disease. Most patients die from malignant bile duct strictures within 6-12 months.

The primary objective in unresectable disease is to provide palliation of the jaundice. Given the morbidity and mortality associated with an operative procedure, nonoperative techniques of palliation are preferred.

Self-expanding metal stents provide effective palliation of malignant biliary strictures and should be considered as an alternative to open surgery.

Metallic stents, although more expensive and not removable once placed, remain patent longer than polyethylene stents; usually a single session of metal stenting can palliate biliary obstruction and, therefore, may be a better choice for the treatment of malignant strictures.

With tumors affecting the bifurcation of the hepatic ducts (Klatskin tumor, shown below), stents can be placed into both the right and left intrahepatic ducts to provide decompression. However, stent placement is technically more difficult in patients with proximal tumors.

Endoscopic retrograde cholangiopancreatographic im Endoscopic retrograde cholangiopancreatographic image of a cholangiocarcinoma at the bifurcation of the right and left hepatic ducts (Klatskin tumor).

Metal stents may become occluded as a result of tumor ingrowth through the open mesh design. A covered, self-expanding metal has been introduced in an effort to reduce the frequency of tumor ingrowth.

More recently, radiofrequency ablation of bile duct strictures has become possible with the introduction of a commercial radiofrequency ablation biliary probe. Ablation therapy may provide prolonged patency of strictures or stents.

Percutaneous transhepatic cholangioplasty and biliary stenting

Similar to endoscopy, the percutaneous balloon dilatation of benign (especially after orthotopic liver transplantation [OLT]) and malignant bile duct strictures and the insertion of plastic or metallic stents are also well tolerated by patients. The stents provide good drainage.

This procedure is executed in a few stages as the tract through the liver is dilated gradually to pass the optimal-size stent. The stent may be completely internalized, with one lumen in the duodenum and the other proximal to the stricture, or it may be an internal-external stent, with one lumen outside and one distal to the stricture.

Percutaneous therapy is associated with a 5-10% rate of major complications.

Operative treatment

Surgical management of benign bile duct strictures is necessary for patients with a low surgical risk in whom endoscopic therapy has failed. Surgical management consists of restoration of biliary enteric continuity, which usually is achieved with a defunctionalized Roux-en-Y jejunal loop by means of hepaticojejunostomy, choledochojejunostomy, or intrahepatic cholangiojejunostomy.

Biliary-enteric anastomosis is a safe, effective, and lasting therapy for biliary strictures. However, before definitive operative therapy for bile duct strictures is performed, patients must be stabilized and, if possible, biliary drainage should be achieved either endoscopically or percutaneously.

Patients with long-standing bile duct strictures due to pancreatitis may require pancreaticoduodenectomy. However, surgical drainage has been associated with considerable morbidity and mortality.

In patients with PSC without cirrhosis, resection of the extrahepatic bile ducts and long-term transhepatic stenting are alternatives to nonoperative dilation with or without stenting and may be associated with a better outcome.

Surgical therapy of malignant bile duct strictures consists of either attempting a curative resection of the tumor or performing a palliative operation. Unfortunately, the surgical cure rate of pancreatic, bile duct, and gallbladder carcinoma causing malignant strictures is dismal. Careful staging of the tumor should be performed in order to select patients who are likely to have surgically resectable disease.

Surgical intervention is recommended for patients who are otherwise healthy, whose disease appears to be localized, or in those with duodenal or gastric outlet obstruction.

Palliative surgery is directed toward relieving jaundice by creating a biliary-enteric anastomosis, and if a gastric or duodenal outlet obstruction is present or is a likely possibility, a gastrojejunostomy should be created at the same time. Although palliative surgery is effective in achieving its goal of circumventing the obstruction, no survival advantage has been described when compared with nonoperative techniques. Thus, for most patients, palliative surgery is not necessary.

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Outpatient Care

Patients with bile duct strictures with percutaneous drains should have their catheters flushed with 5-10 mL of saline once or twice every day to prevent catheter blockage.

Patients should be monitored closely for recurrence of cholangitis and obstructive jaundice, which can occur if the biliary drainage catheters or stents are occluded or if they migrate.

Those treated with biliary stenting with plastic stents or balloon dilatation of bile duct strictures need periodic follow-up with a gastroenterologist or interventional radiologist for stent changes and periodic stricture dilatation.

Patients with external biliary drains should also seek follow-up with an interventional radiologist for catheter exchanges every 2-3 months for internalization of drains.

Those with a malignant obstruction treated with metallic endoprosthesis should be monitored with periodic liver function testing. Progressively abnormal liver function tests suggest stent dysfunction.

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