fbpx

Biliary Obstruction

Updated : May 22, 2024





Background

Biliary obstruction typically refers to the blockage of the bile duct system, which results in impaired bile flow from the liver to the intestinal tract. Bile is a vital substance composed of bilirubin, bile salts, and cholesterol, and it is continually produced in the liver’s hepatocytes. After synthesis, bile is transported through the bile ducts to reach the second portion of the duodenum, which plays a crucial role in fat metabolism. Biliary obstruction primarily refers to the obstruction occurring in the extrahepatic biliary system.

Such obstructions can arise at various points along this path and may lead to severe complications, including hepatic dysfunction, nutritional deficiencies, renal failure, bleeding issues, and infections. Disruption in bile flow due to intrahepatic biliary system impairment is typically termed cholestasis. Cholestasis can manifest as abnormalities in serum hepatic enzymes, such as elevated levels of bilirubin and alkaline phosphatase, often resulting in jaundice and itching.

Biliary obstruction is a widespread issue, affecting a significant portion of the global population, and it carries substantial morbidity and mortality risks. The most common cause of biliary obstruction is choledocholithiasis, commonly known as gallstones, which can block the extrahepatic bile ducts. Among the most severe consequences of this obstruction is the development of bile duct infections, referred to as cholangitis, which can become life-threatening if not promptly treated.

Epidemiology

Gallstones are a common cause of biliary obstruction. The prevalence of gallstones varies by geographic region, age, gender, and ethnicity. Women, individuals over the age of 40, and those with a family history of gallstones are at a higher risk. The prevalence of gallstones is also higher in Western countries compared to some Asian populations.

Gallstones encompass the formation of gallstones and the development of gall bladder sludge, which serves as a precursor to choledocholithiasis. Choledocholithiasis occurs when gallstones traverse the cystic duct and become lodged in the common hepatic duct, resulting in an obstruction. Approximately 10 to 15% of individuals diagnosed with gallstones also exhibit common bile duct stones. Gallstones represent the leading cause of biliary obstruction, especially among Hispanics, Native Americans, and Northern Europeans.

Northern Native Americans exhibit the highest documented rates of cholelithiasis, affecting 64% of females and 29% of males. In contrast, African Americans and Asians have an intermediate prevalence of cholelithiasis, with 5.3% of men and 13.9% of women affected. The lowest prevalence of cholelithiasis is observed in sub-Saharan Black Africa, where it is less than 5%. Among White North Americans, the overall prevalence of cholelithiasis stands at 16.6%, with rates of 8.6% in females and males, respectively.

Anatomy

Pathophysiology

The specific pathophysiology of biliary obstruction can vary based on the location, duration, and cause of the obstruction. When the bile ducts are blocked, bile cannot flow from the liver to the small intestine as it normally would. Bile is essential for the digestion and absorption of dietary fats. Without proper bile flow, fat digestion is compromised, leading to malabsorption of fats and fat-soluble vitamins (A, D, E, K).

As bile accumulates behind the obstruction, the pressure within the bile ducts increases. This increased pressure can lead to the backup of bile into the liver, which can cause liver cell damage and inflammation. Bile contains bilirubin, a waste product from the breakdown of red blood cells.

When bile flow is obstructed, bilirubin is not efficiently excreted from the body. Elevated bilirubin levels in the bloodstream can lead to jaundice, characterized by yellowing of the skin and eyes. Long-term biliary obstruction can result in liver damage, cirrhosis, and impaired liver function. Malabsorption of fats and fat-soluble vitamins can lead to nutritional deficiencies.

Etiology

Gallstones: This is the most frequent cause of biliary obstruction. Gallstones can form in the gallbladder and, in some cases, migrate into the bile ducts, leading to blockage.

Infections: Infections in the bile ducts, such as cholangitis, can cause inflammation and blockages.

Bile Duct Strictures: Narrowing or scarring of the bile ducts due to inflammation, injury, or previous surgical procedures can lead to obstruction.

Trauma: Physical injury to the abdomen or the bile ducts themselves can result in biliary obstruction.

Biliary Atresia: This is a rare congenital condition where an infant is born with poorly formed bile ducts, leading to bile flow problems.

Genetics

Prognostic Factors

Clinical History

Biliary obstruction can manifest in various ways, and its presentation depends on the underlying cause. It is typically characterized by jaundice, dark urine and pale or clay-colored stools. Pruritis, or itching, is a common symptom in cases of chronic biliary obstruction. Additionally, patients may experience a range of other symptoms depending on the specific underlying cause, including right upper quadrant abdominal pain, fever, nausea, vomiting, and unintended weight loss.

The onset of these symptoms can vary widely, with some individuals experiencing a sudden onset while others develop them gradually over several months. A thorough medical history is crucial for evaluating biliary obstruction. It is important to inquire about the duration of symptoms, whether they appeared suddenly or gradually, and whether there are associated symptoms such as weight loss, loss of appetite, nausea, vomiting, or right-sided abdominal pain.

Details about the severity and radiation of abdominal pain are also important. Information about diarrhea, hematochezia, and symptoms of upper gastrointestinal bleeding can provide valuable diagnostic clues. Additionally, it is essential to explore any relevant personal or family history, such as a history of bile duct or pancreatic malignancies, inflammatory bowel disease, or primary liver diseases.

A comprehensive review of the patient’s social history is essential. This includes gathering information about current and past smoking habits, alcohol consumption, and any history of drug abuse. Moreover, a travel history to regions where parasitic infections are endemic can be significant in determining the etiology of biliary obstruction. Finally, a detailed review of the patient’s medication history can sometimes be critical in distinguishing between intrahepatic cholestasis and extrahepatic biliary obstruction.

Physical Examination

A comprehensive and meticulous physical examination is paramount when evaluating biliary obstruction. It is imperative to begin by assessing the patient’s baseline vital signs, paying particular attention to the presence of fever and an elevated heart rate. A general physical examination should be conducted to detect signs of distress, jaundice, pallor, scleral icterus, palmar erythema, and malnutrition.

Conducting a detailed abdominal examination is crucial. This involves evaluating for tenderness in the right upper quadrant, performing Murphy’s sign test, checking for hepatomegaly and splenomegaly, assessing for the presence of ascites, searching for any palpable abdominal masses, and looking for stigmata of cirrhosis, such as the presence of caput medusae.

A cardiac examination is essential to identify signs of congestive heart failure, which may manifest as jugular venous distension and altered heart sound localization. Similarly, a pulmonary examination is necessary to detect pleural effusions and determine whether they are unilateral or bilateral, aiding in diagnosing the underlying cause.

Assessment for lymphadenopathy, particularly in the left supraclavicular lymph nodes (Virchow’s node) and other neck lymph nodes, can provide valuable diagnostic insights. Finally, examining the lower extremities for edema is also important, as it can indicate underlying conditions related to biliary obstruction.

Age group

Associated comorbidity

Associated activity

Acuity of presentation

Differential Diagnoses

Ampullary carcinoma

Acute pancreatitis

Alcoholic hepatitis

Ascariasis

Chronic pancreatitis

Choledochal cysts

Gallbladder cancer

Mirizzi syndrome

Pancreatic cancer

Primary biliary cholangitis

Primary hepatic malignancies

Laboratory Studies

Imaging Studies

Procedures

Histologic Findings

Staging

Treatment Paradigm

In some cases, biliary obstruction may resolve on its own if it is caused by a temporary blockage, such as a small stone passing through the duct. In such cases, conservative management with pain control and close monitoring may be sufficient. If the biliary obstruction is due to cancer, additional treatments such as chemotherapy and radiation therapy may be employed to shrink or control the tumor and relieve the obstruction.

Medications may be prescribed to manage symptoms and underlying conditions. For example, anthelmintics may be used to treat parasitic infections, and medications can relieve pruritus associated with biliary obstruction. Ursodeoxycholic acid may be used to dissolve cholesterol gallstones in some instances.

by Stage

by Modality

Chemotherapy

Radiation Therapy

Surgical Interventions

Surgery may be necessary for more complex cases of biliary obstruction, such as when there are large or multiple stones, strictures, or tumors causing the blockage. Cholecystectomy is often performed if gallstones are the underlying cause of the obstruction. Bypass surgery can be done to reroute the bile flow around the obstruction.

Hormone Therapy

Immunotherapy

Hyperthermia

Photodynamic Therapy

Stem Cell Transplant

Targeted Therapy

Palliative Care

Intervention with a procedure

Endoscopic Procedure 

Endoscopic retrograde cholangiopancreatography (ERCP) is a common procedure used to remove or relieve obstructions in the bile ducts. During ERCP, a flexible tube with a camera is inserted through the mouth and down into the duodenum to access the bile ducts.

Tools can be used to remove gallstones, place stents to keep the ducts open, or perform other interventions. Endoscopic ultrasound (EUS) may also be used to guide procedures and diagnose the cause of biliary obstruction. 

Percutaneous Interventions 

In cases where endoscopic or surgical options are not feasible, percutaneous transhepatic cholangiography (PTC) may be performed. This involves the insertion of a catheter through the skin and into the liver to access the bile ducts and perform procedures like stent placement or stone removal. 

Medication

Media Gallary

References

Biliary Obstruction

Updated : May 22, 2024




Biliary obstruction typically refers to the blockage of the bile duct system, which results in impaired bile flow from the liver to the intestinal tract. Bile is a vital substance composed of bilirubin, bile salts, and cholesterol, and it is continually produced in the liver’s hepatocytes. After synthesis, bile is transported through the bile ducts to reach the second portion of the duodenum, which plays a crucial role in fat metabolism. Biliary obstruction primarily refers to the obstruction occurring in the extrahepatic biliary system.

Such obstructions can arise at various points along this path and may lead to severe complications, including hepatic dysfunction, nutritional deficiencies, renal failure, bleeding issues, and infections. Disruption in bile flow due to intrahepatic biliary system impairment is typically termed cholestasis. Cholestasis can manifest as abnormalities in serum hepatic enzymes, such as elevated levels of bilirubin and alkaline phosphatase, often resulting in jaundice and itching.

Biliary obstruction is a widespread issue, affecting a significant portion of the global population, and it carries substantial morbidity and mortality risks. The most common cause of biliary obstruction is choledocholithiasis, commonly known as gallstones, which can block the extrahepatic bile ducts. Among the most severe consequences of this obstruction is the development of bile duct infections, referred to as cholangitis, which can become life-threatening if not promptly treated.

Gallstones are a common cause of biliary obstruction. The prevalence of gallstones varies by geographic region, age, gender, and ethnicity. Women, individuals over the age of 40, and those with a family history of gallstones are at a higher risk. The prevalence of gallstones is also higher in Western countries compared to some Asian populations.

Gallstones encompass the formation of gallstones and the development of gall bladder sludge, which serves as a precursor to choledocholithiasis. Choledocholithiasis occurs when gallstones traverse the cystic duct and become lodged in the common hepatic duct, resulting in an obstruction. Approximately 10 to 15% of individuals diagnosed with gallstones also exhibit common bile duct stones. Gallstones represent the leading cause of biliary obstruction, especially among Hispanics, Native Americans, and Northern Europeans.

Northern Native Americans exhibit the highest documented rates of cholelithiasis, affecting 64% of females and 29% of males. In contrast, African Americans and Asians have an intermediate prevalence of cholelithiasis, with 5.3% of men and 13.9% of women affected. The lowest prevalence of cholelithiasis is observed in sub-Saharan Black Africa, where it is less than 5%. Among White North Americans, the overall prevalence of cholelithiasis stands at 16.6%, with rates of 8.6% in females and males, respectively.

The specific pathophysiology of biliary obstruction can vary based on the location, duration, and cause of the obstruction. When the bile ducts are blocked, bile cannot flow from the liver to the small intestine as it normally would. Bile is essential for the digestion and absorption of dietary fats. Without proper bile flow, fat digestion is compromised, leading to malabsorption of fats and fat-soluble vitamins (A, D, E, K).

As bile accumulates behind the obstruction, the pressure within the bile ducts increases. This increased pressure can lead to the backup of bile into the liver, which can cause liver cell damage and inflammation. Bile contains bilirubin, a waste product from the breakdown of red blood cells.

When bile flow is obstructed, bilirubin is not efficiently excreted from the body. Elevated bilirubin levels in the bloodstream can lead to jaundice, characterized by yellowing of the skin and eyes. Long-term biliary obstruction can result in liver damage, cirrhosis, and impaired liver function. Malabsorption of fats and fat-soluble vitamins can lead to nutritional deficiencies.

Gallstones: This is the most frequent cause of biliary obstruction. Gallstones can form in the gallbladder and, in some cases, migrate into the bile ducts, leading to blockage.

Infections: Infections in the bile ducts, such as cholangitis, can cause inflammation and blockages.

Bile Duct Strictures: Narrowing or scarring of the bile ducts due to inflammation, injury, or previous surgical procedures can lead to obstruction.

Trauma: Physical injury to the abdomen or the bile ducts themselves can result in biliary obstruction.

Biliary Atresia: This is a rare congenital condition where an infant is born with poorly formed bile ducts, leading to bile flow problems.

Biliary obstruction can manifest in various ways, and its presentation depends on the underlying cause. It is typically characterized by jaundice, dark urine and pale or clay-colored stools. Pruritis, or itching, is a common symptom in cases of chronic biliary obstruction. Additionally, patients may experience a range of other symptoms depending on the specific underlying cause, including right upper quadrant abdominal pain, fever, nausea, vomiting, and unintended weight loss.

The onset of these symptoms can vary widely, with some individuals experiencing a sudden onset while others develop them gradually over several months. A thorough medical history is crucial for evaluating biliary obstruction. It is important to inquire about the duration of symptoms, whether they appeared suddenly or gradually, and whether there are associated symptoms such as weight loss, loss of appetite, nausea, vomiting, or right-sided abdominal pain.

Details about the severity and radiation of abdominal pain are also important. Information about diarrhea, hematochezia, and symptoms of upper gastrointestinal bleeding can provide valuable diagnostic clues. Additionally, it is essential to explore any relevant personal or family history, such as a history of bile duct or pancreatic malignancies, inflammatory bowel disease, or primary liver diseases.

A comprehensive review of the patient’s social history is essential. This includes gathering information about current and past smoking habits, alcohol consumption, and any history of drug abuse. Moreover, a travel history to regions where parasitic infections are endemic can be significant in determining the etiology of biliary obstruction. Finally, a detailed review of the patient’s medication history can sometimes be critical in distinguishing between intrahepatic cholestasis and extrahepatic biliary obstruction.

A comprehensive and meticulous physical examination is paramount when evaluating biliary obstruction. It is imperative to begin by assessing the patient’s baseline vital signs, paying particular attention to the presence of fever and an elevated heart rate. A general physical examination should be conducted to detect signs of distress, jaundice, pallor, scleral icterus, palmar erythema, and malnutrition.

Conducting a detailed abdominal examination is crucial. This involves evaluating for tenderness in the right upper quadrant, performing Murphy’s sign test, checking for hepatomegaly and splenomegaly, assessing for the presence of ascites, searching for any palpable abdominal masses, and looking for stigmata of cirrhosis, such as the presence of caput medusae.

A cardiac examination is essential to identify signs of congestive heart failure, which may manifest as jugular venous distension and altered heart sound localization. Similarly, a pulmonary examination is necessary to detect pleural effusions and determine whether they are unilateral or bilateral, aiding in diagnosing the underlying cause.

Assessment for lymphadenopathy, particularly in the left supraclavicular lymph nodes (Virchow’s node) and other neck lymph nodes, can provide valuable diagnostic insights. Finally, examining the lower extremities for edema is also important, as it can indicate underlying conditions related to biliary obstruction.

Ampullary carcinoma

Acute pancreatitis

Alcoholic hepatitis

Ascariasis

Chronic pancreatitis

Choledochal cysts

Gallbladder cancer

Mirizzi syndrome

Pancreatic cancer

Primary biliary cholangitis

Primary hepatic malignancies

In some cases, biliary obstruction may resolve on its own if it is caused by a temporary blockage, such as a small stone passing through the duct. In such cases, conservative management with pain control and close monitoring may be sufficient. If the biliary obstruction is due to cancer, additional treatments such as chemotherapy and radiation therapy may be employed to shrink or control the tumor and relieve the obstruction.

Medications may be prescribed to manage symptoms and underlying conditions. For example, anthelmintics may be used to treat parasitic infections, and medications can relieve pruritus associated with biliary obstruction. Ursodeoxycholic acid may be used to dissolve cholesterol gallstones in some instances.

Surgery may be necessary for more complex cases of biliary obstruction, such as when there are large or multiple stones, strictures, or tumors causing the blockage. Cholecystectomy is often performed if gallstones are the underlying cause of the obstruction. Bypass surgery can be done to reroute the bile flow around the obstruction.

Endoscopic Procedure 

Endoscopic retrograde cholangiopancreatography (ERCP) is a common procedure used to remove or relieve obstructions in the bile ducts. During ERCP, a flexible tube with a camera is inserted through the mouth and down into the duodenum to access the bile ducts.

Tools can be used to remove gallstones, place stents to keep the ducts open, or perform other interventions. Endoscopic ultrasound (EUS) may also be used to guide procedures and diagnose the cause of biliary obstruction. 

Percutaneous Interventions 

In cases where endoscopic or surgical options are not feasible, percutaneous transhepatic cholangiography (PTC) may be performed. This involves the insertion of a catheter through the skin and into the liver to access the bile ducts and perform procedures like stent placement or stone removal.