Approach Considerations
Admit the patient for prompt necessary diagnostic testing, supportive care, and surgical intervention if indicated. Transfer may be required for further diagnostic evaluation and treatment.
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).
Consultations with a gastroenterologist, radiologist, and general surgeon are recommended.
Following discharge, monitor patients regularly to ensure that they respond to treatment and that the diagnosis is correct.
Medical Care
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.
In cases of malignant biliary obstruction, a meta-analysis suggests that endoscopic nasobiliary drainage (ENBD) is more effective and safe than endoscopic biliary stenting (EBS) with regard to preoperative and postoperative complications such as the postoperative pancreatic fistula rate, the incidence of stent dysfunction, and morbidity. [15] However, the meta-analysis did not include data from randomized controlled trials.
Pharmacotherapy
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.
Preoperative preparation includes nutritional support, hydration, correction of coagulopathy, and perioperative antibiotics.
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. Risk of bile duct injury during laparoscopic cholecystectomy is around 0.4-0.6%.
Gallstones and common bile duct (CBD) stones can be treated with preoperative endoscopic removal of CBD stones followed by laparoscopic cholecystectomy or laparoscopic cholecystectomy and choledocholithotomy.
Choledochal cyst requires excision and hepaticojejunosotmy. Biliary obstruction in chronic pancreatitis may need a biliary-enteric anastomosis at the time of the drainage of the pancreatic duct.
Resectability of neoplastic causes of biliary obstruction varies with respect to the location and extent of the disease. Preoperative biliary drainage may be required before a major liver resection. 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. [16, 17] 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.
Endoscopic biliary stenting is considered first-line treatment for unresectable malignant hilar biliary obstruction and for distal biliary obstruction, with self-expandable metal stents (SEMSs) preferred over plastic stents in patients expected to live longer than 3 months. [18] Bilateral or unilateral stent insertion appear to be equally effective with similar long-term outcomes for patients with malignant hilar biliary obstruction. [19] Percutaneous transhepatic endobiliary radiofrequency ablation in combination with biliary stenting may hold potential for safely and effectively restoring biliary drainage in patients with malignant biliary obstruction based on the findings of a Turkish study in 21 patients. [20]
Findings from the WATCH-2 study appear to show comparable rates of recurrent biliary obstruction, time to recurrent biliary obstruction, and survival between patients with unresectable distal malignant biliary obstruction undergoing fully covered (n = 151) or partially covered (n = 141) SEMSs. [21] In addition, there was also no significant difference in the rate of stent migration between the two groups.
In a separate international multicenter study of endoscopic management of combined distal malignant biliary obstruction and duodenal obstruction in 110 patients, transpapillary or transmural endoscopic biliary drainage with a duodenal stent was effective in 95% of the patients, regardless of the timing or location of the duodenal obstruction. [22] Time to recurrent biliary obstruction was longer for metal versus plastic stents, and a higher rate of adverse events was associated with endoscopic ultrasonographic-guided biliary drainage relative to endoscopic retrograde cholangiopancreatography (ERCP).
In a single-center retrospective study (2013-2015) of 520 therapeutic ERCP, of which 45 cases failed ERCP, Nakai et al found similar technical success and ERCP-related adverse events among patients who underwent ERCP, rescue percutaneous transhepatic biliary drainage (PTBD), primary EUS-BD, and endoscopic ultrasonography-guided biliary drainage (EUS-BD). [23] Based on their findings, the investigators suggested that primary EUS-BD without failed ERCP may be a treatment option if it provides advantages over ERCP.
Liver transplantation may be considered in appropriate patients (eg, end-stage liver disease [ESLD], primary sclerosing cholangitis [PSC], hepatocellular carcinoma [HCC], secondary biliary cirrhosis and portal hypertension.
Diet and Activity
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.
Patients should reduce their intake of saturated fats and increase their fiber intake. High intake of fiber has been linked to a lower risk for gallstones.
Reduction in sugar intake is recommended, 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.
Prevention
Awareness of the risk factors and clinical signs/symptoms of biliary obstruction is key to the prompt diagnosis and treatment of biliary obstruction, with the hope of preventing the potential complications it may cause.
In patients with risk factors for developing any of the conditions that lead to biliary obstruction, awareness of the signs and symptoms can improve chances for early diagnosis and improved outcome.
Gallstones are the most common cause of biliary obstruction. Estrogens cause an increase in the risk for formation of gallstones and may need to be avoided in patients with known gallstones or a strong family history of stone disease.
