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Biliary stricture

What's new

Added 2023 ACG, 2023 ESMO, 2022 TAGE, 2021 ESGE, 2019 BSG, and 2015 ASGE guidelines for the diagnosis and management of biliary strictures.

Background

Overview

Definition
Biliary stricture refers to a narrowing or constriction of the bile ducts, which can impede the flow of bile from the liver to the intestine.
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Pathophysiology
The pathophysiology of biliary stricture often involves injury to the bile duct, which can result from surgical procedures, trauma, or inflammation due to conditions like cholangitis or choledocholithiasis. This injury can lead to fibrosis and stricture formation.
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Epidemiology
The incidence of biliary stricture is estimated to range between 0.2-0.7% in patients who have undergone cholecystectomy, and 15.2-22.9% at 1 year in living donor liver transplantation.
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Risk factors
Risk factors for biliary stricture include a history of liver transplantation, especially from living donors or following cardiac death, and conditions that cause inflammation or damage to the bile ducts, such as surgical procedures, PSC, and choledocholithiasis.
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Disease course
Clinically, biliary stricture can present with jaundice, pruritus, dark urine, pale stools, and abdominal pain. If left untreated, complications can arise, including cholangitis, biliary cirrhosis, and portal hypertension.
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Prognosis and risk of recurrence
The prognosis of biliary stricture depends on the underlying cause and the effectiveness of the treatment. However, with appropriate treatment, the prognosis can be favorable.
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Guidelines

Key sources

The following summarized guidelines for the evaluation and management of biliary stricture are prepared by our editorial team based on guidelines from the American College of Gastroenterology (ACG 2023), the European Society of Medical Oncology (ESMO 2023,2016), the Thai Association for Gastrointestinal Endoscopy (TAGE/T-CAP 2022), the European Society of Gastrointestinal Endoscopy (ESGE 2021,2020,2019,2018), the Thai Association for Gastrointestinal Endoscopy (TAGE/T-CAP/DEST ...
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Diagnostic investigations

Evaluation of extrahepatic strictures, abdominal ultrasound: as per ESMO 2016 guidelines, consider obtaining abdominal ultrasound in the initial evaluation to identify biliary obstruction in patients with biliary tract cancer.
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  • Evaluation of extrahepatic strictures (CT/MRI)

  • Evaluation of extrahepatic strictures (ERCP)

  • Evaluation of extrahepatic strictures (EUS with FNA)

  • Evaluation of extrahepatic strictures (cholangioscopy and intraductal ultrasound)

  • Evaluation of perihilar strictures

  • Evaluation of indeterminate strictures

  • Evaluation of PSC

  • Evaluation of postoperative biliary obstruction

Therapeutic procedures

Biliary drainage, extrahepatic obstruction, benign causes: as per ACG 2023 guidelines, perform placement of a fully covered self-expanding metallic stent over multiple plastic stents in parallel to reduce the procedures required for long-term treatment in patients with extrahepatic stricture caused by a benign condition.
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  • Biliary drainage (extrahepatic obstruction, malignant causes)

  • Biliary drainage (perihilar obstruction)

  • Removal of biliary stents

  • Adjunctive therapies

Perioperative care

Preprocedural antibiotic prophylaxis
As per ESGE 2020 guidelines:
Do not administer routine antibiotic prophylaxis before ERCP.
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Consider administering antibiotic prophylaxis (with an agent active against Gram-negative bacteria and adapted as much as possible to local epidemiology) before ERCP in case of anticipated incomplete biliary drainage, in severely immunocompromised patients, and when performing cholangioscopy.
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  • Pre-stenting sphincterotomy

Surgical interventions

Indications for surgery, hepatic aspergillosis: as per IDSA 2016 guidelines, consider performing surgical intervention in patients with extrahepatic or perihepatic biliary obstruction caused by hepatic aspergillosis.
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  • Indications for surgery (sphincter of Oddi dysfunction)

Specific circumstances

Patients with an indwelling biliary catheter: as per DEST/T-CAP/TAGE 2020 guidelines, recognize that cholangitis in patients with an indwelling biliary stent suggests recurrent biliary obstruction and may require early endoscopic re-intervention.
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