Bile Duct Cancer

What is a bile duct stricture?

Narrowing of the bile duct is also called as bile duct stricture. The stricture prevents bile from draining into the intestine. The bile thus backs up into the liver and bilirubin rises in the blood to cause jaundice.

What are some other names for bile duct stricture?

• Biliary stricture
  
  

What are the causes of biliary stricture? How does it progress?

• Broadly, bile duct strictures can be of two types:

• Benign (non-cancerous)

• Malignant (cancerous)
  
  

The most common cause for a benign bile duct stricture is trauma to the bile duct during a laparoscopic cholecystectomy (keyhole surgery for removal of gall bladder for stones). It is estimated that approximately 0.1% to 1% of gallbladder operations may lead to injury to the bile duct with subsequently leading to a bile duct stricture. Injury to the hepatic artery (blood vessel of the liver) may also cause bile duct stricture.

Other causes of benign bile duct stricture are:

• Gall bladder stones that move into the bile duct (bile duct stones) causing repeated inflammation, damage and scarring of bile duct, leading to stricture

• Pancreatitis

• Primary Sclerosing Cholangitis (PSC)

Bile duct strictures caused by cancer of the bile duct are discussed in details elsewhere on this website.

Bile duct strictures can cause significant problems due to recurrent obstructive jaundice, right upper quadrant abdominal pain, and recurrent episodes of ascending cholangitis (infection in the bile duct).

What are the signs and symptoms of bile duct injury / biliary strictures

Bile duct injury is commonly diagnosed few days after laparoscopic surgery for gall baldder removal (laparoscopic cholecystectomy). Patients generally have fever, jaundice and pain in the abdomen. Ultrasound or CT scan of the abdomen may show a collection of bile. A MRCP, HIDA scan or ERCP may show the actual site and type of injury.

Bile strictures most commonly lead to jaundice i.e. yellowness of urine, eyes and skin. The stricture prevents flow of bile into the intestines (as it happens normally) and instead spills into the blood. It may also lead to pale or clay coloured stools (bile makes the stools yellow in color). Excessive bile salts in blood may deposit under the skin causing severe itching all over the body.

If the bile static inside the liver gets infected, it may lead to cholangitis i.e. infection in bile, which manifests as abdominal pain and fever with chills.

Which tests and examinations are required to diagnose / evaluate this disease?

• Alkaline Phosphatase (ALP) and GGTP (Gamma glutaryl transferase) maybe raised

• Bilirubin (predominantly direct / conjugated bilirubin) may be raised

• Amylase and Lipase are pancreatic enzymes, the levels of which may be raised because of destruction of pancreatic cells

• Urine bilirubin may be raised, because more bilirubin is excreted through the kidneys

• Fat absorption may be impaired because of lack of some digestive enzymes and fecal fat may be raised

• If the stricture is left untreated for a long time, it may affect liver function and prothrombin time (INR) may be elevated

The following tests can help diagnose this condition:

• Magnetic resonance cholangiopancreatography (MRCP): It is a special type of MRI scan. MRCP helps in confirming and locating the stricture. Bile duct stones may also be seen on MRCP.

• Endoscopic retrograde cholagiopancreatography (ERCP) is a type of endoscopy where the bile ducts can be seen with Xrays. ERCP can not only be used to identify the location and size of stricture, but also help in treating it.

• Percutaneous Transhepatic cholangiography (PTC) is a procedure where an interventional radiologist identifies the stricture by putting contrast into the bile ducts. It is generally used when ERCP fails. This approach can also be used to treat the stricture by putting a per-cutaneous biliary drain (PTBD) or a stent.

What is the best treatment of bile duct strictures?

Endoscopic treatment: ERCP may be used to dilate the stricture and put a stent across it. The stents may have to changed a couple of times every few months before it is removed.

Percutaneous Transhepatic cholangiography (PTC) is a procedure where an interventional radiologist identifies the stricture by putting contrast into the bile ducts. It is generally used when ERCP fails. This approach can also be used to treat the stricture by putting a per-cutaneous biliary drain (PTBD) or a stent. Sometimes, multiple drains may be required.

Surgical treatment (hepatico-jejunostomy): In cases where the above modalities fail or are not feasible, a surgical bypass of the bile duct may be performed, the procedure is called hepatico-jejunostomy. This surgery involves connecting healthy bile duct beyond to stricture area directly with the intestine.

What is the expected outcome of treatment?

Treatment of bile duct injury and benign bile duct strictures is usually successful with one of the above modalities. Patients with underlying diseases such as PSC have less favorable outcome compared to others.