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Gastroenterology and Hepatology

Bile Duct Strictures

Virginia Mason is an international center for treating biliary strictures with endoscopic therapies. A biliary stricture, also called a bile duct stricture, is a narrowing of a bile duct from scar tissue within the duct itself. Scar tissue can form for any number of reasons: a bile duct stone, as a result of bile duct surgery or abdominal radiation treatment, infection or inflammation (pancreatitis), a traumatic injury to the abdomen, alcohol or drug use, or from a chronic inflammatory condition called primary sclerosing cholangitis, which is a narrowing of bile ducts within the liver. A biliary stricture can be benign (noncancerous) or malignant (cancerous). The biliary and pancreatic ducts also can become narrowed and obstructed by a tumor within the gallbladder, liver or pancreas.

A stricture can block the release of bile — which helps absorb food — from the liver and gallbladder and lead to a serious infection within the liver called ascending cholangitis. For more information or to schedule an appointment, call (206) 223-2319.

Symptoms of a Bile Duct Stricture

Bile ducts are small, about four to 10 millimeters, or 1/6th to slightly less than half an inch in diameter and can be easily blocked by scar tissue, a tumor or a stone. Fortunately, a bile duct stricture is an uncommon occurrence.

Disorders of the bile duct oftentimes have the same symptoms because most of them block these small ducts from releasing bile or digestive enzymes into the small intestine. Symptoms of a bile duct stricture may occur over several years as scar tissue develops.

Common symptoms and signs of a bile duct stricture include:

  • Abdominal pain on the right side of the body (where the liver and gallbladder are located)
  • Itching (a common symptom)
  • Yellow skin or eyes (from the buildup of bilirubin, a waste product)
  • Fatigue
  • Weight loss
  • Fever
  • Night sweats
  • Loss of appetite
  • Light-colored stools

Serious complications
A bile duct stricture that completely blocks a bile duct can lead to inflammation of organs within or outside of the biliary tree (gallbladder, liver and pancreas) as well as a serious bacterial infection within the liver (ascending cholangitis). Low blood pressure and sepsis (an infection within the blood stream) can result from these complications. The presence of any symptoms shown above should be brought to the attention of a physician without delay.

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Diagnosing a Bile Duct Stricture

Your gastroenterologist may suspect a bile duct disorder based on your appearance, a description of your symptoms, and whether a blood test shows high levels of bilirubin, a waste product in blood from the normal breakdown of red blood cells. A definitive diagnosis is made through a procedure called ERCP, or endoscopic retrograde cholangiopancreatography, which allows your gastroenterologist to view the biliary and pancreatic ducts.

Additional tests and procedures for diagnosing the presence of a bile duct stricture include the following:

  • BLOOD TESTS
    In addition to a bilirubin test, your blood may be tested for the presence of elevated white blood cells used by the body to fight infection, and for abnormal levels of pancreatic and liver enzymes. Other blood tests may be performed to rule out liver disorders.
     
  • ABDOMINAL ULTRASOUND
    This non-invasive procedure uses sound waves rather than x-rays to produce images. The images can reveal a narrowing within the common bile duct. During this procedure, an ultrasound probe is passed over the abdomen and images are sent to a computer monitor. Abdominal ultrasound is commonly used in women who are pregnant.
     
  • ABDOMINAL CT SCAN OR MRI A CT scan of the abdomen or MRI also can identify narrowing within the biliary tract and is a noninvasive procedure. During these scans, images are shown on a computer monitor.
     
  • MRCP
    Magnetic resonance cholangiopancreatography (MRCP) is performed in Radiology using MRI technology (magnets and radio waves) to produce computer images of the gallbladder, pancreas and bile ducts. A contrast dye is injected first into a vein to enhance the images. Patients are not required to undergo endoscopy preparation and they do not undergo sedation. MRCP is being used primarily in patients who may have failed or who are not good candidates for ERCP, in those who do not want to undergo an endoscopic procedure, and in individuals considered to be at low risk of having a pancreatic duct or bile duct disorder. While ERCP allows for therapeutic options with cholangioscopy, MRCP is a diagnostic tool only.
     
    Virginia Mason also is involved in national clinical trials to determine the accuracy of MRCP in diagnosing disorders of the biliary tract.
     
  • ERCP AND/OR EUS
    Endoscopic retrograde cholangiopancreatography, or ERCP, is a specialized endoscopic technique used to study the gallbladder, pancreas and bile ducts, and has the added benefit of being a therapeutic tool. ERCP has been in use for more than 40 years, and is considered the standard modality for diagnosing and treating disorders of the biliary tract.
     
    During ERCP, patients first receive an anesthetic to numb the throat along with a sedative. Your gastroenterologist will then pass a flexible endoscope with a miniature TV camera inside through your mouth and into the stomach and small intestine. When your gastroenterologist sees the opening of the bile and pancreatic ducts on a monitor, he or she then passes a catheter (a narrow plastic tube) containing a contrast dye through the endoscope. The dye is injected into the biliary and pancreatic ducts and x-rays are taken that are viewed on a computer monitor. The procedure takes 60-90 minutes and is performed in the Endoscopy Suite within Virginia Mason's Section of Gastroenterology and Hepatology.
     
    Your gastroenterologist can pass a thin ultrasound probe through the ERCP endoscope. Alternatively, endoscopic ultrasound, or EUS, which uses ultrasound images in place of x-rays for better viewing of the bile and pancreatic ducts can be done with a specially designed endoscope.
     
    Gastroenterologists can treat disorders of the bile duct with miniaturized instruments passed through the ERCP endoscope. One such procedure for treating a bile duct stricture is placing a small stent (a hollow tube) within the bile duct to keep it open.
     
    Special preparations are required for this endoscopic procedure. Please see the ERCP and EUS prep planners for more information.
     
  • PERCUTANEOUS TRANSHEPATIC CHOLANGIOGRAM
    This procedure, performed by a radiologist, is an x-ray of the bile ducts inside and outside of the liver, and shows drainage of bile from the liver. After first receiving a local anesthetic, a long, thin needle is inserted through the abdominal skin (percutaneously) and into the liver. The needle injects a contrast dye near the ducts to be studied and images are shown on a fluoroscopic monitor. The images can reveal whether the bile ducts are enlarged, indicating that a stricture or stone may be blocking the duct.

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Treating a Bile Duct Stricture

Once a bile duct stricture has been diagnosed, treatment will depend on the severity of symptoms and the degree of narrowing within the duct.

  • MEDICAL THERAPY
    Patients who have inflammation or infection (cholangitis) within a bile duct are treated first with antibiotics. The majority of patients respond to this medical therapy, during which time a definitive determination can be made for endoscopic or surgical therapy.
     
  • ENDOSCOPIC THERAPY
    A bile duct stricture is commonly treated by placing a small stent (a hollow tube) within the bile duct to keep it open. This procedure can be performed at the time of diagnosis with miniaturized surgical instruments inserted through the ERCP endoscope.
     
    If the narrowing or stricture completely blocks the bile duct - and if it is amenable to dilation or enlargement - it can be widened first with a procedure called balloon dilation. A balloon on the tip of a catheter is passed through the ERCP endoscope and is inflated at the site of the stricture, enlarging the blocked duct. A stent, also passed through the ERCP endoscope, is then placed within the duct and opened.
      
  • PERCUTANEOUS THERAPY
    When an ERCP procedure is not the best option for the patient, a percutaneous (through the skin) procedure to dilate a stricture and place a stent can be done instead.
     
  • SURGICAL THERAPY
    Surgical treatment is recommended when endoscopic therapy is not successful or if the bile duct stricture cannot be treated by endoscopic or percutaneous means. During surgery, our Liver, Pancreas and Biliary Surgical team removes the stricture and connects the bile duct to the small intestine. This open surgical procedure is performed in the operating room under a general anesthetic.

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