From the Guidelines
Obstructive biliary disease should be managed with prompt relief of the obstruction, typically involving endoscopic retrograde cholangiopancreatography (ERCP) with stone removal or stent placement, to prevent serious complications such as cholangitis, sepsis, and liver damage 1.
Causes and Symptoms
Obstructive biliary disease occurs when there is a blockage in the bile ducts, preventing bile from flowing from the liver to the small intestine. The most common cause of cholangitis is choledocholithiasis, which is the presence of gallstones in the common bile duct 1. Symptoms may include pain, jaundice, infection, and acute pancreatitis.
Acute Management
For acute management, patients may need:
- Intravenous fluids
- Antibiotics, such as piperacillin-tazobactam 4.5g IV every 8 hours or ciprofloxacin 400mg IV every 12 hours plus metronidazole 500mg IV every 8 hours, if infection is present 1
- Pain management
Definitive Treatment
Definitive treatment requires removing the obstruction, which may involve:
- Endoscopic retrograde cholangiopancreatography (ERCP) with stone removal or stent placement
- Percutaneous transhepatic cholangiography (PTC) with drainage
- Surgery For gallstone-related obstruction, cholecystectomy is often performed after the acute phase resolves 1. Patients with malignant obstruction may need stenting or surgical bypass procedures.
Monitoring and Support
Patients should be monitored for signs of infection, such as fever and increased white blood cell count, worsening jaundice, and liver function. Nutritional support may be necessary, particularly in prolonged cases or when malignancy is the underlying cause 1.
Key Recommendations
- ERCP plays a central role in the management of biliary obstruction in patients with acute cholangitis 1
- Percutaneous biliary drainage (PTBD) should be reserved for patients in whom ERCP fails 1
- Open drainage should only be used in patients for whom endoscopic or percutaneous trans-hepatic drainage is contraindicated or those in whom it has been unsuccessfully performed 1
From the Research
Obstructive Biliary Disease Management
- Obstructive biliary disease can be managed through various procedures, including endoscopic retrograde cholangiopancreatography (ERCP) with stent placement, percutaneous transhepatic biliary drainage (PTBD), and endoscopic ultrasound-guided biliary drainage (EUS-BD) 2, 3, 4.
- ERCP with stent placement is a commonly used method for relieving biliary obstruction, with high success rates and few adverse events 2, 5.
- PTBD can be used as an adjunct to ERCP in cases where ERCP is not feasible or has failed, with a high technical success rate and few complications 4.
- EUS-BD is a promising alternative to surgical bypass and PTBD, with high success rates and fewer adverse events compared to PTBD 3, 6.
Comparison of Procedures
- A study comparing initial ERCP with stent placement and initial PTBD for relief of biliary obstruction in patients with unresectable cholangiocarcinoma found that both methods were safe and effective, with similar procedure success rates and rates of cholangitis 2.
- Another study found that EUS-BD had a high success rate and few adverse events, making it a viable alternative to PTBD and surgical bypass 3.
- A retrospective study found that PTBD was an important adjunctive drainage procedure in patients with ERCP failure or post-ERCP cholangitis, with a high technical success rate and few complications 4.
Prognostic Factors
- A study investigating long-term survival and prognostic factors after biliary ERCP drainage for obstruction jaundice secondary to metastatic cancer found that good ECOG performance status and post-drainage treatment were independent predictors of overall survival 5.
- Another study found that successful drainage, absence of ascites, and post-drainage treatment were factors associated with improved survival in patients with malignant biliary obstruction caused by metastatic cancer 5.