biliary tract obstruction



Overview

Diseases of the hepatobiliary system causing obstruction of bile outflow leading to jaundice, liver function abnormalities, etc. Jaundice, dark urine, white clay stools, abdominal pain, abdominal distension, etc. Gallbladder and bile duct stones, biliopancreatic tumors, bile duct stenosis, etc. Medication, ERCP lithotripsy, surgery, etc.

Definition

Biliary obstruction is a condition in which the outflow of bile is blocked due to diseases or abnormalities in the gallbladder, liver, or bile ducts, causing a series of symptoms such as jaundice and abnormal liver function.

Common causes include bile duct stones or inflammation, benign or malignant tumors of the bile duct, benign or malignant tumors of the liver, benign or malignant tumors or inflammatory lesions of the pancreas, and congenital structural variations of the bile duct.

Severe biliary obstruction can lead to liver failure, infection and even death.

Classification

Biliary obstruction can be categorized according to the location, degree and cause of obstruction:

According to the location of obstruction

Intrahepatic bile duct obstruction;

Hepatoportal bile duct obstruction;

Extra-biliary bile duct obstruction.

According to the degree of obstruction

Partial obstruction;

Complete obstruction.

According to the cause of the obstruction

Congenital biliary obstruction;

Stone biliary obstruction;

Inflammatory biliary obstruction;

Neoplastic biliary obstruction.

Morbidity

Biliary obstruction is a common condition whose incidence varies slightly from region to region.

Cholelithiasis is the most common cause of biliary obstruction, with a prevalence of 10% to 15% in adults. In China, the incidence of cholelithiasis is relatively high, ranging from about 5% to 10%.

Biliary obstruction due to benign and malignant tumors of the liver, gallbladder, and pancreas is also common. The incidence of biliary obstruction due to other causes is relatively low, but should not be ignored.

Causes

Causes

Biliary tract obstruction can be caused by a variety of factors, including the following:

Gallbladder and bile duct stones

Cholelithiasis is the most common cause of biliary obstruction. Stones can obstruct the gallbladder, intra- and extra-hepatic bile ducts, and common bile ducts, interfering with bile drainage.

Inflammatory bile duct stenosis

Due to inflammation, surgery, injury, infection, etc., the bile ducts may become narrowed, which can lead to obstruction of bile flow.

Bile duct tumor

Malignant tumors such as cholangiocarcinoma and gallbladder cancer, as well as perihepatic bile duct tumors that invade or compress the bile ducts may lead to bile duct obstruction.

Inflammatory lesions of pancreas

Acute or chronic pancreatitis may lead to biliary obstruction, especially when the pancreatic head is inflamed.

Benign and malignant tumors of the pancreas

Pancreatic tumors (especially pancreatic head tumors) may invade or compress the bile ducts, leading to biliary obstruction.

Parasitic infections

Parasitic infections in some areas, such as Ascaris lumbricoides, Treponema pallidum, and Hepatic schistosomes, may invade the biliary system and cause biliary obstruction.

Congenital anomalies

Abnormalities in the development of the biliary tract, such as congenital biliary stenosis and biliary atresia, may also lead to biliary obstruction.

Functional biliary obstruction

In some cases, the flow of bile may be obstructed by dysfunction of the sphincter of the pygidium due to a lack of function of the biliary system in the absence of obvious structural abnormalities, a condition known as functional biliary obstruction.

Symptoms

Main Symptoms

Jaundice symptoms

Yellowing of skin and sclera: Jaundice is the most common symptom of biliary obstruction. As bile cannot be excreted from the body, the concentration of bilirubin in the blood increases, resulting in yellowing of the patient’s skin and sclera.

Darkening of urine color: Due to the increase of bilirubin in the blood, bilirubin is formed in the kidneys after decomposition, which leads to darkening of urine.

Light or colorless stools: Bile cannot enter the intestines due to biliary obstruction, and the stools will become light white clay-like or lose color.

Digestive tract symptoms

Upper abdominal distension: may be caused by increased pressure in the bile ducts due to gallstones or tumors.

Nausea, vomiting and loss of appetite: Bile cannot enter the duodenum and the gastrointestinal tract is susceptible to discomfort, leading to symptoms such as nausea, vomiting and loss of appetite.

Fever and chills: Infectious lesions such as those due to chronic cholangitis can also lead to signs of infection, such as fever and chills.

Abdominal mass: If there is obstruction due to tumor in the bile ducts, an abdominal mass can be present.

Itchy skin.

When bile is stagnant, bile components such as bilirubin flow back into the bloodstream. As the blood circulates throughout the body, the bilirubin causes yellowing of the sclera, and bile salts accumulate under the skin and directly stimulate the skin’s sensory endings, resulting in itching of the patient’s skin.

Complications

Cholestatic hepatitis

Prolonged stasis of bile will lead to infection and inflammation of the biliary tract, inflammation of the liver and biliary system, and even lead to cirrhosis and liver failure.

Bile Duct Dilation

Prolonged obstruction of the bile ducts increases the internal pressure, causing dilatation of the bile ducts, which may even rupture in severe cases.

Cholecystitis

Obstruction of the emptying of the gallbladder can lead to the growth of pathogens and progress to cholecystitis.

Pancreatitis

The return of bile to the pancreas can affect the secretion and degradation of pancreatic enzymes, leading to chronic pancreatitis.

Cholangiocarcinoma

Prolonged untreated biliary obstruction, cholestasis, and prolonged inflammatory response can increase the risk of developing biliary tract cancer.

Consultation

Department of Medicine

Gastroenterology

If you experience symptoms such as jaundice, abdominal pain, nausea, vomiting, etc., please consult the Department of Gastroenterology, which focuses on initial diagnosis of biliary tract obstruction and development of a treatment plan.

Hepatobiliary Surgery

If surgical treatment is required, you may need to visit the Department of Hepatobiliary Surgery or the Department of General Surgery.

Preparation for medical treatment

Preparation for medical consultation: registration, preparation of information, common problems

Tips for your visit

You should record your medical history and symptoms before going to the doctor. This will help the doctor to better understand your condition and provide the right treatment.

Preparation Checklist

Symptom list

Pay particular attention to the time of onset of symptoms, special manifestations, etc.

Is there abdominal distension or bloating?

Any fever, abdominal pain, diarrhea?

Do you have dark-colored urine?

Nausea, vomiting?

Has there been a significant change in weight recently?

Any yellowing of the skin or eyes all over the body?

How long have the above symptoms lasted?

List of medical history

Any previous illnesses such as cholecystitis, gallbladder stones, etc.?

Any previous illnesses such as hepatitis, cirrhosis, cholangitis, etc.?

Any past malignant tumors such as gallbladder cancer, bile duct cancer, pancreatic cancer, liver cancer, etc.?

Surgical history: Patients need to provide whether they have suffered from liver and gallbladder diseases in the past, have undergone surgical treatment, etc.

Drug history: patients need to provide the types of drugs taken in the past, the duration of medication and the therapeutic effect.

Dietary and alcohol history: patients need to provide dietary habits, whether there is overeating, eating junk food and other bad dietary habits. Also need to provide whether there has been a history of alcohol consumption, the frequency and amount of alcohol consumption.

Checklist

Test results of the last six months, which can be brought to the doctor’s office

Laboratory tests: blood test, liver function.

Imaging tests: abdominal ultrasound, abdominal CT, magnetic resonance cholangiopancreatography (MRCP).

Gastrointestinal endoscopy: transendoscopic retrograde cholangiopancreatography (ERCP).

Other tests: e.g. blood culture, bile culture, etc.

Diagnosis

Diagnosis is based on

Medical history

Presence of cholecystitis, cholelithiasis, etc.

History of parasitic disease of the hepatobiliary tract: e.g. liver worm, schistosomiasis, etc.

There are hepatitis, cirrhosis, cholangitis, etc.

There are malignant tumors such as gallbladder cancer, bile duct cancer, pancreatic cancer, etc.

Pancreatitis, intestinal adhesions, etc.

Clinical manifestations

Symptoms

Patients have yellowing of the skin, eyes and mucous membranes, darkening of the urine, and light or colorless stools.

Patients may also exhibit gastrointestinal symptoms such as nausea, vomiting, loss of appetite, epigastric distension and pain.

Itchy skin.

Physical Signs.

Patients may present with signs such as pressure and pain in the abdomen and hepatosplenomegaly. Significant pressure pain is especially present in the right upper abdomen, and the area of pressure pain may spread to the right scapula and other areas.

The patient’s skin, eyes and mucous membranes may show obvious yellow coloration.

Some patients may develop abdominal wall masses.

Laboratory Tests

Routine blood tests

Check hemoglobin, white blood cell count, platelets and other indicators to determine whether there are infections and anemia.

Liver function tests

Include serum aspartate transferase (AST), alanine aminotransferase (ALT), bilirubin and other indicators to assess the condition of liver function.

Tumor markers, coagulation function tests

Other tests

Blood culture, bile culture, etc. can be used to clarify the infection.

Imaging

Abdominal ultrasound can examine the abnormalities of liver, gallbladder and bile ducts, and has high accuracy in the diagnosis of biliary obstruction.

Enhanced CT of the abdomen can further clarify the location, cause and complexity of biliary obstruction and the relationship between biliary and pancreatic lesions and blood vessels.

Magnetic resonance cholangiopancreatography (MRCP) can produce three-dimensional images of the biliary tract to diagnose diseases of the gallbladder, bile ducts and pancreas.

Endoscopy

Transendoscopic retrograde cholangiopancreatography (ERCP): is an interventional procedure in which a gastroscope is inserted retrogradely into the bile ducts and contrast is injected to directly observe the bile ducts, as well as treatments such as biopsy, sphincterotomy, and gallstone removal.

Differential diagnosis

In the differential diagnosis of biliary obstruction, it is necessary to take into account a variety of factors such as the patient’s history, symptoms, signs and imaging examinations in order to make a clear diagnosis and carry out appropriate treatment.

Acute cholecystitis

Acute cholecystitis presents with symptoms such as right upper abdominal pain and fever, which may be similar to biliary obstruction. However, acute cholecystitis is usually not associated with jaundice.

Hepatitis

Acute or chronic hepatitis may also cause jaundice, but it is usually accompanied by other manifestations of liver inflammation, such as elevated ALT and AST.

Cirrhosis

Cirrhosis of the liver may cause symptoms such as jaundice, ascites, and splenomegaly, and bears some resemblance to biliary obstruction. However, cirrhosis usually has a history of chronic liver disease and other complications.

Hemolytic jaundice

Hemolytic jaundice is jaundice due to excessive red blood cell destruction and is usually associated with anemia and elevated reticulocytes.

Hereditary non-hemolytic jaundice

As in Gilbert’s syndrome, this condition results in a mild elevation of serum indirect bilirubin and may be similar to jaundice caused by biliary obstruction. However, this type of jaundice is usually asymptomatic and the biliary tract is structurally normal.

Treatment

Aims of treatment: restoration of normal bile flow, relief of pain, prevention of complications and prevention of recurrence.

Principles of treatment: Determine the cause of the disease, relieve the obstruction, treat the symptoms and prevent complications.

Supportive treatment

Maintaining water-electrolyte balance

Biliary obstruction may lead to water-electrolyte disorders, such as low potassium and sodium.

Doctors will give appropriate rehydration and electrolyte supplementation treatment according to the patient’s laboratory test results.

Anti-infection treatment

Biliary obstruction may lead to infections, such as cholangitis and cholecystitis.

According to the results of bacterial culture and drug sensitivity, appropriate antibiotic treatment will be given. Fluoroquinolones (e.g. moxifloxacin), third and fourth generation cephalosporins (cefoperazone, ceftriaxone, ceftazidime) can be chosen.

Nutritional support

Supplemental nutrition, mainly low-fat, high-calorie, high-protein, fat-soluble vitamins should be supplemented with fat-soluble vitamins and calcium in patients with fat-soluble vitamin deficiency.

Analgesic treatment

Biliary obstruction may be accompanied by abdominal pain, appropriate analgesic drugs, such as pethidine and tramadol, can be given according to the degree of pain.

Hepatoprotective treatment

Biliary obstruction may lead to impaired liver function. During treatment, the doctor may give some liver-protecting drugs, such as glutathione and glycyrrhizin, to protect the liver.

Endoscopic treatment

Endoscopic treatment for biliary obstruction mainly refers to endoscopic retrograde cholangiopancreatography (ERCP) treatment.ERCP is a commonly used and safe and effective treatment for biliary obstruction.

Biliary stone extraction

ERCP can be used to treat bile duct obstruction by inserting a guide wire into the interior of the bile duct through an endoscope and removing the stone through instruments such as a balloon or mesh basket.

Biopsy and Brushing for Bile Duct Obstruction

If a patient has a bile duct stenosis or blockage due to a bile duct tumor or external pressure lesion, ERCP can biopsy and brush the inside of the bile duct to diagnose the cause.

Incision of the stenosis or placement of a stent

If the patient has a more severe bile duct stricture or obstruction, ERCP can use a scalpel or thermal probe to incise the stricture or place a stent to reopen the bile duct.

Surgery

Biliary obstruction requires surgical treatment in some cases, and treatment options include:

Choledochotomy for stone removal

Choledochotomy and lithotripsy may be considered if there are stones lodged in the jugular abdomen of the bile duct and the pancreatic duct after cholecystectomy.

Resection of benign and malignant tumors of the liver, gallbladder and pancreas

Resection of benign and malignant tumors of the liver, gallbladder and pancreas that cause obstruction of the bile ducts.

Bile duct-intestinal anastomosis

If the biliary obstruction is caused by a stricture or mass between the bile ducts, after resection of the lesion, a bile duct-jejunum anastomosis may be performed.

Interventional therapy

Interventional treatment for biliary obstruction mainly includes percutaneous transcystic retrograde cholangiography (PTCD) and percutaneous transhepatic biliary stenting.

PTCD

PTCD is a procedure in which a puncture needle is passed through the skin into the bile duct and a guidewire is introduced into the bile duct.

During PTCD, the lumen of the bile duct is dilated, and an appropriately sized endoprosthesis can be placed through the dilated bile duct to treat severe bile duct stenosis, tumors, and other diseases.

Percutaneous transhepatic biliary stenting

By placing a bile duct stent in the narrowed or obstructed area of the bile duct, the bile duct is restored to its original lumen diameter by supporting the wall of the bile duct, thus restoring the smoothness of the bile duct.

Prognosis

Cure

Cure of biliary obstruction depends on a number of factors including the cause, extent and severity of the obstruction. Generally speaking, if the bile duct obstruction is caused by bile duct stones, most of them can be cured and prevented from recurring after timely removal of the stones.

If the obstruction is caused by a bile duct tumor, the treatment plan should be determined according to the benignity and spread of the tumor. If the tumor is detected at an early stage and treated in a timely manner, the chance of cure is higher; if it has spread to other organs or lymph nodes, the possibility of cure will be reduced accordingly.

For some patients who are not suitable for surgical treatment or those with advanced cancer, percutaneous hepatic puncture and drainage, endoscopy and other treatments to alleviate the symptoms of obstruction may be used. These treatments can relieve symptoms such as jaundice and abdominal pain and improve the quality of life of patients.

In conclusion, the cure of biliary obstruction depends on a variety of factors, and the appropriate treatment plan needs to be selected according to the patient’s specific situation. Early detection and treatment can increase the possibility of cure and avoid further deterioration of the condition.

Daily

Daily Management

Diet

Patients should avoid eating too much greasy, spicy and stimulating food, and choose more light and easy-to-digest diets to protect the gastrointestinal tract and reduce the burden on the gallbladder and pancreas.

Rest

Patients with biliary tract obstruction need to maintain sufficient rest and sleep to reduce the burden on the body and promote recovery.

Psychological support

If a patient is feeling anxious, depressed, or other emotions, support can be obtained through psychotherapy. Examples include attending psychological counselling, and participating in diversionary and counselling activities organized by psychological professionals.

Personal hygiene

Patients with biliary tract obstruction need to pay special attention to personal hygiene and keep their bodies clean and dry.

Rehabilitation

After the patient’s condition improves, rehabilitation exercises should be carried out appropriately to enhance physical fitness and promote recovery.

Disease monitoring

Condition monitoring of biliary tract obstruction can be carried out in the following aspects:

Clinical manifestations

Regularly observe the patient’s clinical manifestations, including jaundice, abdominal pain, nausea, vomiting, loss of appetite and other symptoms with or without significant changes.

Imaging examination

Regular imaging examinations, such as abdominal ultrasound, CT, MRI, etc., are needed to observe whether the bile duct is patent.

Other examinations

Patients need to undergo blood routine, blood biochemistry, coagulation function and other tests according to the situation.

Biliary stent replacement

For patients with implanted biliary stent, regular stent replacement is needed to ensure the effectiveness of the stent.

Supervision

Patients with particularly severe biliary obstruction require monitoring of respiration, circulation, urine output, and other indicators, as well as ambulatory electrocardiography and blood gas analysis when necessary.

Follow-up review

Follow-up review of biliary obstruction should be performed at the end of treatment to detect and assess the patient’s recovery and cure.

Physical examination

Physical examination should be performed at each review, including measurement of weight, height and temperature, checking whether the liver and spleen size are normal and whether there is jaundice.

Imaging examination

Several weeks after the patient is discharged from the hospital, imaging tests, such as abdominal ultrasound and CT, should be arranged to determine whether the biliary tract is patent.

Laboratory tests

Regular checks of blood routine, blood biochemistry, coagulation function and other indicators are needed.

Follow-up frequency

For patients with biliary tract obstruction, weekly review can be conducted in the initial stage, and then gradually reduced to once a month, and the time of review can be adjusted according to the specific situation of the patient and changes in the condition.

Symptom review

Patients should take the initiative to reflect their symptoms to the doctor during the follow-up process, and inform the doctor of any uncomfortable symptoms and receive further examination and treatment.

Prevention

Diet

In terms of diet, we should avoid high-fat, spicy, greasy and stimulating foods, drink less drinks, alcohol and other stimulating beverages, and eat more vegetables, fruits, coarse grains and other foods that are good for the body.

Proper Exercise

Maintain good living habits and physical health, appropriate physical exercise, adequate sleep and rest.

Regular review

Regularly go to the hospital for rechecking, pay attention to the testing of liver function, blood lipids and blood glucose and other indexes to keep abreast of your physical condition and prevent potential risks from developing into biliary obstruction.

Pay attention to the use of drugs

For people with gallbladder, pancreas, bile duct and other diseases, avoid abusing drugs, especially hepatotoxic drugs taken for a long period of time, so as not to aggravate the condition.

Receive regular treatment

In the presence of biliary tract, gallbladder and pancreatic diseases, regular treatment should be received to ensure the effectiveness of treatment in order to avoid recurrence and aggravation of the disease.