Bile Duct Strictures

Background
Bile duct stricture (biliary stricture) is an uncommon but challenging clinical condition that requires a coordinated multidisciplinary approach involving gastroenterologists, radiologists, and surgical specialists. Unfortunately, most benign bile duct strictures (biliary strictures) are iatrogenic, resulting from operative trauma (see images below).[1] Bile duct strictures (biliary strictures) may be asymptomatic but, if ignored, can cause life-threatening complications, such as ascending cholangitis,[2, 3] liver abscess, and secondary biliary cirrhosis.

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Focal intrahepatic benign bile duct stricture after cholecystectomy.
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Percutaneous transhepatic cholangiogram with balloon dilation of a postoperative bile duct stricture. However, not all bile duct strictures (biliary strictures) are benign. Pancreatic cancer is the most common cause of malignant biliary strictures (see images below).[4, 5] Most of these patients die of complications of tumor invasion and metastasis rather than from the bile duct stricture (biliary stricture) per se. Nonetheless, both benign and malignant bile duct strictures can be associated with distressing symptoms and excessive morbidity.[6]

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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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Focal bile duct stricture as a result of pancreatic cancer in the head of the pancreas. For excellent patient education resources, visit eMedicineHealth's Digestive Disorders Center and Infections Center. Also, see eMedicineHealth's patient education articles Cirrhosis and Gallstones.
Pathophysiology
Strictures of the bile duct can be benign or malignant. Benign strictures develop when the bile ducts are injured in some way. The injury may be a single acute event, such as damage to the bile ducts during surgery or trauma to the abdomen; a recurring condition, such as pancreatitis or bile duct stones; or a chronic disease, such as primary sclerosing cholangitis (PSC). After the injury, an inflammatory response ensues, which is followed by collagen deposition, fibrosis, and narrowing of the bile duct lumen (see images below).

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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 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. Depending on the nature of the insult, bile duct strictures (biliary strictures) can be single or multiple. Atrophy of the hepatic segment or lobe drained by the involved bile ducts, associated with hypertrophy of the unaffected segments, can occur, especially with chronic high-grade strictures. These changes can eventually progress to secondary biliary cirrhosis and portal hypertension.
Malignant strictures are usually the result of either a primary bile duct cancer (ie, causing a narrowing of the bile duct lumen and obstructing the flow of bile) or extrinsic compression of the bile ducts by a neoplasm in an adjacent organ, such as the gallbladder, pancreas, or liver (see image below).

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Endoscopic retrograde cholangiopancreatographic cholangiogram demonstrating a long bile duct stricture that represents external compression by gallbladder cancer.
Epidemiology
Frequency
United StatesAlthough quite uncommon, the exact prevalence of bile duct strictures (biliary strictures) is unknown. One major category of bile duct strictures is postoperative bile duct stricture, which usually occurs as a result of a technical mishap during cholecystectomy, causing bile duct injury. Data from many large series of patients in the United States have revealed that the incidence rate of major bile duct injury is 0.2-0.3% after open cholecystectomy and 0.4-0.6% after a laparoscopic cholecystectomy.
InternationalData from Europe have shown a similar rate to the United States of occurrence of postoperative bile duct strictures.
Mortality/Morbidity

  • Bile duct strictures, independent of etiology, can cause significant morbidity from recurrent obstructive jaundice, right upper quadrant abdominal pain, biliary stones, and recurrent episodes of ascending cholangitis (see image below).
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    Multiple small bile duct stones seen on magnetic resonance cholangiopancreatography (MRCP).
  • The major determinant of mortality in patients with bile duct strictures is the underlying disease condition. Patients with biliary strictures due to operative injury, radiation, trauma, or chronic pancreatitis generally have a good prognosis. Conversely, patients with bile duct strictures due to PSC and malignancy have a less favorable outcome.

Sex
  • Data on the overall sex ratio of bile duct strictures are lacking. Some conditions causing bile duct strictures, such as PSC and chronic pancreatitis, are more common in men. The incidence of postcholecystectomy strictures is comparable in men and women.

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