Excerpt from Bile Duct Strictures

Synonyms, Key Words, and Related Terms: biliary stricture, biliary stenosis, operative trauma, surgical trauma, ascending cholangitis, liver abscess, secondary biliary cirrhosis, pancreatic cancer, benign strictures, malignant strictures, bile duct injury, pancreatitis, bile duct stones, primary sclerosing cholangitis, PSC, postoperative bile duct stricture, cholecystectomy, Charcot triad, cholangiocarcinoma

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Background: Bile duct stricture is an uncommon but challenging clinical condition requiring a coordinated multidisciplinary approach involving gastroenterologists, radiologists, and surgical specialists. Unfortunately, most benign bile duct strictures are iatrogenic, resulting from operative trauma. Bile duct strictures may be asymptomatic but, if ignored, can cause life-threatening complications, such as ascending cholangitis, liver abscess, and secondary biliary cirrhosis. However, not all strictures are benign. Pancreatic cancer is the most common cause of malignant biliary strictures. Most of these patients die of complications of tumor invasion and metastasis rather than from the biliary stricture, per se. Nonetheless, both benign and malignant strictures can be associated with distressing symptoms and excessive morbidity.

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.

Depending on the nature of the insult, bile duct 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 usually are 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.

Frequency:

In the US: Although quite uncommon, the exact prevalence of bile duct 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.

Internationally: Data from Europe have shown a similar rate 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.

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.