Bile Duct Obstruction
Bile duct (or biliary) obstruction occurs for numerous reasons. Causes can include cancerous and non-cancerous processes as well as injuries from medical procedures or operations. Obstruction can occur at different levels of the bile duct tree (Figure 1a).
Given the many reasons for bile duct obstruction, a multidisciplinary approach is needed to effectively diagnose and treat patients. At the University Medical Center of Southern Nevada, our team of surgeons, radiologists, interventional endoscopists and oncologists offer treatment for a wide variety of biliary obstruction cases.
The presence of a cancerous lesion(s) within the hepatobiliary system can also lead to bile duct obstruction. In these cases, optimal treatment requires a multimodal approach that includes a surgeon, oncologist and interventionalist (endoscopist and radiologist) and radiation oncologists.
Cancers of the bile ducts within the liver, liver cancers or cancers metastatic to the liver can cause obstruction of the bile duct system. Diagnosis is usually made by radiographic studies (CT or MRI). Prior to treatment of the obstruction, a full work-up of the lesion to determine the extent of disease is necessary. Additionally, a biopsy of the lesion may be needed, which is usually performed with CT or ultrasound guidance. Imaging of the bile ducts within the liver are obtained via radiologic (PTC or percutaneous transhepatic cholangiography) and/or interventional endoscopic (ERCP) procedures. Treatment depends on the extent, location and type of cancer (Figure 1b). An endoscopic ultrasound (EUS) may be required to determine the extent of disease. Interventional approaches can be used to treat the obstruction if the patient is not a surgical candidate.
Extrahepatic Bile Duct Cancers
An extrahepatic bile duct cancer refers to all cancers that arise within the bile duct system below the liver (Figure 1b). Diagnosis is usually made by radiological imaging. Further elucidation with ERCP, PTC and EUS may be required. Brushings and subsequent pathological examination of the bile duct help with the diagnosis. Surgical versus interventional approaches are assessed on a patient-by-patient basis.
Pancreatic cancers can cause obstruction of the bile duct just as it enters the intestine (Figure 1b). Diagnosis is usually made radiographically. Treatment of this patient requires a multidisciplinary approach encompassing surgeons, oncologists, radiologists and radiation oncologists for an optimal outcome.
Biliary stricturing (narrowing) or obstruction may be the result of an injury sustained during a medical procedure. For example, a gallbladder operation or endoscopic procedure can cause a bile duct injury or transection. Surgeons usually treat a bile duct transection at time of injury if noticed.
Bile duct injuries that do not cause bile spillage but cause strictures are usually treated when symptoms arise. Patients often have pain, fever and/or jaundice, as well as elevation in liver laboratory tests. Operative treatment is usually required.
Cholelithiasis (Gallstones) and Biliary Stones
Gallstones or biliary stones can pass from the gallbladder or liver, respectively, into the common bile duct and proceed into the small intestine depending on their size. As they pass through the biliary tree, these stones may cause obstructions if they are lodged in the bile duct. Additionally, strictures may occur due to repeated trauma to the bile duct lining (Figure 2).
Interventional endoscopists can extract lodged stones in the common bile duct tree by performing a procedure called an ERCP (endoscopic retrograde cholangiopancreatography). Similarly, strictures can be treated by an interventional endoscopist or interventional radiologist, depending on the site of the problem and issues related to the patient’s surgical candidacy. After stone removal, further operations may be necessary to remove the source of the stones (gallbladder or part of the liver).
Biliary leaks result when bile extravasates (leaks) through defects in the bile duct wall. This leakage can occur anywhere within the bile duct system. Most commonly, biliary leaks are the result of medical procedures, operations, or traumatic injuries to the biliary system. The end result is bile leakage into the abdomen or surrounding tissues. Interventional approaches (interventional radiologic procedures and interventional endoscopic procedures) are able to treat a majority of the injuries. Surgery may be needed in some situations.
Biliary Leaks by Location
Bile duct leaks can occur after a liver operation or trauma in which a portion of the liver is removed or injured. The edge of the cut liver can leak bile. If this happens, a collection of bile forms at the edge of the liver. This is called a "biloma". Individuals will usually present with pain and fever if the biloma is infected. Treatment usually involves placement of a drainage catheter directly into the biloma by the interventional radiologist to drain the collection. The interventional endoscopist then places a stent into the biliary system adjacent to the leaking duct to allow bile to drain via the normal route rather than leak out. Further surgical intervention is needed if the leak remains persistent.
Common bile duct
Common bile duct injuries can occur during gallbladder operations or endoscopic interventions of the common bile duct. During a gallbladder operation, the common bile duct can be injured or a clip placed on the cystic duct may fall off at a later time leading to bile leakage. If the injury is noticed during the initial operation, the surgeon will fix the bile duct injury with a Roux-en-Y choledochojejunostomy. For leaks that are not noticed at the original operation, treatment is similar to that described above for hepatic injuries. The pancreas is also a site of common bile duct injuries, usually as the result of interventional endoscopy. Surgical intervention with drain placement is required if the patient develops a leak. Sometimes diversion of the bile flow may be needed with a Roux-en-Y choledochojejunostomy.
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