Biliary Stricture

Biliary stricture is narrowing of the bile duct (common hepatic, common bile or intrahepatic ducts) that impedes bile flow, either benign or malignant.

• Malignant causes: cholangiocarcinoma (hilar, intrahepatic, distal), pancreatic head cancer, gallbladder cancer, ampullary cancer, metastatic nodes, hepatocellular carcinoma.
• Benign causes: postoperative injury, chronic pancreatitis, primary sclerosing cholangitis, IgG4 related disease, stones and Mirizzi syndrome, ischaemia, radiotherapy, infections (HIV cholangiopathy, ascariasis, liver flukes, tuberculosis), and portal biliopathy.
• Distinguishing benign from malignant is the central diagnostic task.

Painless progressive jaundice, pruritus, dark urine, pale stools, weight loss, anorexia (malignant); intermittent jaundice, right upper quadrant pain and recurrent cholangitis (benign).

• Cholangitis: fever with rigors, jaundice and right upper quadrant pain; hypotension and confusion in severe disease.
• Courvoisier sign (palpable nontender gallbladder) suggests distal malignant obstruction.
• Differential diagnosis: choledocholithiasis, hepatitis, drug-induced cholestasis, primary biliary cholangitis, intrahepatic cholestasis of pregnancy, hepatocellular jaundice, haemolysis, Gilbert syndrome.
• Complications: cholangitis, hepatic abscess, secondary biliary cirrhosis, portal hypertension, coagulopathy from vitamin K deficiency, malnutrition, sepsis, renal failure and bile leak.

Cholestatic liver profile (raised alkaline phosphatase and gamma-glutamyl transferase, conjugated hyperbilirubinaemia), INR, full blood count, CRP, blood cultures if febrile.

• Ultrasound (dilated ducts), then contrast CT or MRI with MRCP to define the level and length of stricture.
• Endoscopic ultrasound with fine needle aspiration of nodes or masses; endoscopic retrograde cholangiopancreatography with brush cytology, intraductal biopsy, and fluorescence in situ hybridisation; cholangioscopy with direct visualisation and targeted biopsy.
• Tumour markers (CA 19-9 is raised in jaundice from benign obstruction too); serum IgG4 (above 1.35 g/L suggests IgG4 disease); autoimmune markers; viral serology.
• Staging scans (chest, abdomen, pelvis) for suspected malignancy.

Supportive: correct coagulopathy (vitamin K 10 mg IV daily for 3 days), fluids, nutritional support, pruritus (cholestyramine 4 g up to three times daily, rifampicin 150 to 300 mg twice daily, or naltrexone 25 to 50 mg daily).

Pharmacological

• Cholangitis: piperacillin-tazobactam 4.5 g IV every 6 to 8 hours, or ceftriaxone 2 g IV daily plus metronidazole 500 mg IV every 8 hours (meropenem 1 g every 8 hours in severe disease); continue until 4 to 7 days after biliary drainage.
• IgG4 related stricture: prednisolone 30 to 40 mg daily (0.6 mg/kg) for 4 weeks, then taper by 5 mg every 2 weeks, with azathioprine 2 mg/kg for relapse.
• Malignant disease: chemotherapy (gemcitabine plus cisplatin for biliary cancer; gemcitabine-based regimens for pancreatic cancer) by oncology.

Procedures

• Urgent biliary decompression for cholangitis: endoscopic stent or nasobiliary drain, or percutaneous transhepatic drainage if endoscopy fails.
• Malignant distal stricture: self-expanding metal stent (preferred for palliation, patency 6 to 12 months) or plastic stent if prognosis is short; resection (pancreaticoduodenectomy) when resectable; liver resection for hilar cancer; transplant in selected hilar cholangiocarcinoma.
• Benign stricture: stricture dilation with multiple plastic stents or a fully covered metal stent for 6 to 12 months, percutaneous balloon dilation, or surgical bilioenteric reconstruction (Roux-en-Y hepaticojejunostomy).
• Photodynamic therapy or radiofrequency ablation for unresectable cholangiocarcinoma in selected centres.

Special groups: HIV cholangiopathy (antiretroviral therapy, sphincterotomy), primary sclerosing cholangitis (transplant evaluation; surveillance for cholangiocarcinoma), children (biliary atresia needs early surgery).

Red flags: cholangitis, septic shock, weight loss, new mass, rising CA 19-9, failure to drain.

Follow-up: liver profile 1 to 2 weeks after stenting; stent change every 3 months (plastic) or at 6 to 12 months (metal) or when jaundice recurs; palliative care for advanced malignancy.