Cause Of Biliary Stricture Research Articles

Tubercular Biliary Hilar Stricture Treated with Antitubercular Drug: a Case Report and Review of Literature

Tuberculosis (TB) of the hepatobiliary system is a rare cause of biliary stricture. Obstructive jaundice secondary to tubercular lymphadenitis is an uncommon presentation. Most cases of tubercular biliary hilar stricture are diagnosed postoperatively. Tuberculosis must be considered in the differential diagnosis of hilar biliary obstruction in patients from tuberculosis endemic areas. The authors report the first case of hilar stricture of tuberculosis which was diagnosed on chest X-ray, fine needle aspiration cytology from periportal lymph node, not on surgical pathology and improved on anti-tubercular treatment (ATT).

The role of endoscopic ultrasound in biliary strictures

The role of endoscopic ultrasound (EUS) in the diagnosis of biliary strictures is well established, and emerging evidence suggests it may also play a therapeutic role. Differentiating between benign and malignant causes of biliary strictures can be challenging, but EUS can aid in their diagnosis and may predict resectability. The diagnostic yield of EUS combined with fine-needle aspiration (FNA) is excellent, especially in distal bile duct strictures, and far surpasses endoscopic retrograde cholangiopancreatography (ERCP) with brushings. Intraductal ultrasound may add to the diagnostic sensitivity of ERCP with brushings when no mass is seen on cross-sectional imaging or EUS, or when EUS with FNA is negative and suspicion of cancer persists. EUS-guided cholangiography is an emerging technique that may aid biliary decompression when ERCP has failed or is not possible; however, new therapeutic echoendoscopes or accessories are needed before the use of this technique can become more widespread.

Ischemic Mass Effect from Biliary Surgical Clips

Migrating surgical clips in the hepatic hilum are known causes of biliary stricture or obstruction, most often due to direct intraluminal obstruction or secondary stone formation. Two cases are reported on patients with previous cholecystectomies presenting with delayed symptoms of biliary tract stricture. Both patients were successfully treated with a resection of the strictured area and a Roux-en-Y hepatico-jejunostomy. Resected specimens grossly demonstrated surgical clips adjacent to the stricture, but not directly within the lumen, suggestive of an ischemic mass effect, which was supported by histology. In addition to the direct intraluminal obstruction and lithogenic effects of migratory surgical clips, "clipomas" due to an ischemic mass effect can also lead to biliary tract strictures.

Resolution of tuberculous biliary stricture after medical therapy

Tuberculosis (TB) is a very rare cause of biliary stricture that is difficult to diagnose and usually requires surgical intervention in order to rule out underlying malignant etiology. We report a 56-year-old man presented with jaundice, weight loss and poor appetite. Initial work up showed the dilated biliary system secondary to distal common bile duct stricture. Investigations to define the etiology of this stricture showed inconclusive brush cytology with absent abdominal masses and lymph nodes but enlarged mediastinal lymph nodes. Biopsy from these lymph nodes showed a non-caseating epitheliod granuloma with negative acid fast bacilli (AFB) stain. The patient had a dramatic response to empirical anti-tuberculosis therapy. Six weeks later, culture from lymph nodes was positive for Mycobacterium tuberculosis. Three months later, follow-up cholangiogram showed complete resolution of the stricture with normalization of liver enzymes 6 mo after starting anti-tuberculosis therapy. Treatment was continued for 12 mo and the patient had a normal life with normal liver enzymes and regression of the mediastinal lymph nodes at the time when he was reported in this paper. Although 16 cases of tuberculous biliary stricture are available in the English literature, up to our knowledge, this is the second published report of tuberculous biliary stricture, which resolved completely after medical therapy alone and the second reported case from the Middle East. This report emphasizes the importance of keeping TB as a possibility of biliary stricture in this part of the world.

Distinguishing between recurrent primary sclerosing cholangitis and chronic rejection

1. Recurrent primary sclerosing cholangitis (PSC) is extremely difficult, if not impossible, to distinguish from other causes of biliary strictures or sclerosing cholangitis in allografts using needle biopsy evaluation alone. Technical problems with biliary reconstruction, long cold ischemic times, non-heart beating donors, ABO blood group incompatibility, antibody-mediated rejection, and small-for-size syndrome in reduced-size or living donor livers can also cause similar manifestations in a peripheral core biopsy. 2. Some difficulties in distinguishing between sclerosing cholangitis and chronic rejection (CR) arise because: a) at risk populations are similar; b) both can cause "cholestatic" elevation of liver injury tests; and c) both can lead to intrahepatic cholestasis and small bile duct loss. 3. Etiopathogenesis and pathology of CR and sclerosing cholangitis have some overlapping features, but show distinct differences that result in significantly different and discriminating pathologic manifestations. 4. Clues in the clinical history, evaluation of serial biopsies, and histopathology can be used to distinguish with confidence between sclerosing cholangitis and CR. 5. Potential discriminating features include liver size and gross appearance, and histopathology findings in the arterial tree, hilar lymph nodes, large and small bile ducts, interface zone, lobular, and perivenular regions.

Recurrent primary sclerosing cholangitis: From an academic illusion to a clinical reality

Recurrent primary sclerosing cholangitis: From an academic illusion to a clinical reality

Endoscopic management of the liver transplant patient

Endoscopic management of the liver transplant patient

MRCP for Evaluating Biliary Strictures

The accuracy of magnetic resonance cholangiopancreatograpy (MRCP) for detecting causes of biliary strictures has not been assessed definitively. In

Recurrence of primary sclerosing cholangitis after liver transplantation.

Orthotopic liver transplantation (OLT) has become the only effective therapeutic option for patients with end-stage liver disease caused by primary sclerosing cholangitis (PSC). Excellent long-term outcome has been reported, with 5-year patient survival rates of approximately 80%. In the last few years, increasing evidence has emerged that PSC recurs after OLT. The diagnosis of PSC is based on well-defined cholangiographic features combined with biochemical and histological findings. However, none of these features is specific for PSC, particularly after OLT, because biliary strictures in the liver allograft can occur from a variety of causes other than recurrence. Therefore, PSC recurrence remains a controversial issue, especially because of a lack of a gold standard for diagnosis and well-established diagnostic criteria. Some reports provided cholangiographic evidence that post-OLT biliary strictures occurred more frequently in patients with PSC than in those who underwent OLT for other liver diseases (including patients with a Roux-en-Y biliary reconstruction). Because no other possible cause of biliary strictures could be invoked to explain the greater prevalence of these strictures, recurrent disease has been implicated. There also is histological evidence suggesting that PSC recurs after OLT. Histological findings suggestive of PSC were found more often in PSC allografts compared with a control group. Furthermore, histological features typical for PSC (fibro-obliterative lesions) were seen exclusively in liver biopsy specimens from patients with PSC. Recurrence of PSC was defined in a recent study from the Mayo Clinic by means of strict cholangiographic and histological criteria in a large cohort of patients with PSC in whom other causes of biliary strictures were excluded. PSC recurrence was found in 20% of patients. No risk factor for PSC recurrence could be found, and recurrent disease did not influence patient or graft survival after a mean follow-up of 4.5 years. In conclusion, several studies provided convincing evidence that PSC recurs after OLT, with an incidence of 5% to 20% and an interval to diagnosis of at least 1 year after OLT. To date, patient and graft survival do not appear to be negatively affected by disease recurrence in the intermediate term of follow-up.

Uncommon biliary strictures

The majority of benign biliary strictures are secondary to iatrogenic injury at surgery, sclerosing cholangitis, or chronic pancreatitis. There are several more uncommon causes of benign strictures of the bile ducts. These include recurrent pyogenic cholangitis, Mirizzi's syndrome, retroperitoneal fibrosis, and biliary varices. There are even rarer causes such as tuberculous involvement of the biliary tree, other infections such as schistosomiasis, common bile duct webs, and rare vascular anomalies. Management of the underlying cause of biliary strictures is warranted but radiological, endoscopic, or surgical intervention is often necessary for the strictures per se. The etiology, presentation, investigation, and management of uncommon biliary strictures are detailed in this article.

An unusual cause of biliary stricture in a patient with neurofibromatosis type 1

The majority of biliary strictures occur as a consequence of iatrogenic injury to the extrahepatic biliary tract, with more than 80% following cholecystectomy. The laparoscopic era has led to heightened awareness of this problem. The occurrence of an iatrogenic stricture can be particularly devastating to both patient and surgeon. The literature highlights a number of factors involved in the aetiology of such traumatic stricture formation. We report an unusual case of a Bismuth 2 stricture of the proximal common hepatic duct,occurring in a patient with type 1 neurofibromatosis, following an iatrogenic bile duct injury that occurred during a laparoscopic cholecystectomy. Histological examination of the strictured region of bile duct removed at surgery demonstrated multiple neurofibromas of varying sizes present in the submucosa. Neurofibromatosis type 1 (von Recklinghausen disease) affects the gastrointestinal tract in up to 25% of cases, and in such cases is characterized by multiple submucosal neurofibromas. We believe this is the first reported case of a biliary stricture in a patient with neurofibromatosis type 1, which appeared to be as a consequence of neurofibromas in the submucosa of the bile duct.

4640 A prospective randomised controlled trial of prophylactic versus symptomatic plastic stent exchange for palliation of malignant biliary obstruction.

Background: Endoscopic stent insertion is the optimum method of palliation for malignant biliary obstruction. Plastic stents are much cheaper than the metal alternatives which are only cost effective in longer surviving patients. However plastic stents are prone to occlusion and the optimal strategy for replacement of plastic stents prior to occlusion remains uncertain. Aim: To compare the outcome of patients with inoperable malignant biliary obstruction palliated by either elective plastic stent exchange or symptomatic exchange when the stent occludes. Methods: Patients with inoperable malignant biliary obstruction that had been successfully treated by ERCP and plastic stent insertion were recruited from 3 centres. They were randomised to either elective plastic stent exchange every 3 months or exchange when symptoms suggestive of stent obstruction developed. All patients were followed up for a minimum of 4 months or until death. Results: Forty patients (18 male, mean age 75 yrs (range 47-90 yrs) were randomised to one of two groups: symptomatic (n=18) or elective (n=22) stent replacement. The cause of biliary stricture was pancreatic cancer in 21 cases, cholangiocarcinoma in 16, ampullary tumor in 2 and metastases in 1. The median follow-up period was 117 days (range 2 435 days) and 34 patients died during follow-up. Overall survival rates were 88%, 63% and 30% at 30, 90 and 180 days. Only 8 (36%) of the elective group actually underwent elective replacement at 3 months, the remainder died before exchange (8), refused exchange (2), occluded before exchange (1) or were unfit for procedure (3). In total, 18 repeat ERCPs were performed in the elective group and 6 in the symptomatic group (p=0.26). Treatment group did not significantly effect survival rates or frequency of stent exchange. Kaplan-Meier analysis showed no significant difference in survival between the two treatment groups (p=0.87). Conclusions: A strategy to electively replace plastic stents in patients with inoperable malignant biliary obstruction does not significantly improve patient survival and is only likely to impact on a minority of patients due to the generally poor survival of such cohorts.