From the Guidelines
Biliary fistula diagnosis and treatment should prioritize endoscopic interventions, such as ERCP with stent placement, as the preferred approach for benign biliary strictures, according to the most recent evidence. Biliary fistula is diagnosed through a combination of clinical presentation, laboratory tests, and imaging studies, including ultrasound, CT scan, MRCP, ERCP, or fistulography to identify the location and extent of the fistula 1. Patients typically present with bile drainage from a wound, abdominal pain, fever, and jaundice.
Treatment depends on the cause, location, and severity of the fistula, with conservative management often being the first approach, including:
- Drainage of collections
- Nutritional support
- Antibiotics, such as piperacillin-tazobactam 4.5g IV every 8 hours or ciprofloxacin 400mg IV twice daily plus metronidazole 500mg IV three times daily, for infection Endoscopic interventions like ERCP with stent placement or sphincterotomy can help reduce pressure in the biliary system and promote healing. Specifically, FCSEMS placement is favored over multiple plastic stents whenever feasible, given similar efficacy but significantly reduced need for stent exchange procedures during the treatment course 1. For persistent fistulas, somatostatin analogs like octreotide may reduce biliary secretions. Surgical intervention becomes necessary for fistulas that don't respond to conservative measures, with options including direct repair, biliary reconstruction, or partial hepatectomy depending on the location and complexity.
The underlying pathophysiology involves abnormal connections between the biliary tract and another surface, often resulting from surgical complications, trauma, or disease processes that disrupt the normal biliary anatomy. While other studies suggest the use of endoscopic internal biliary catheters with removable plastic stents for patients with dilated bile ducts and moderate to massive ascites 1, the most recent and highest quality evidence supports the use of ERCP with stent placement as the preferred treatment for benign biliary strictures 1.
From the Research
Classification of Biliary Fistula
- Biliary fistula is a type of enterocutaneous fistula that arises from the biliary tree or pancreas 2
- It can be classified as low-output or high-output fistula, depending on the volume of fluid loss per day 3, 2
Diagnosis of Biliary Fistula
- Diagnosis is typically made based on clinical presentation, imaging studies, and laboratory tests 4
- Imaging studies such as CT scans or ultrasound may be used to locate the fistula and assess its output 3
Treatment Options for Biliary Fistula
- Conservative treatment with total parenteral nutrition, skin care, and infection control is often the initial approach 5, 6
- Octreotide, a somatostatin analogue, may be used to reduce fistula output and promote closure 5, 2, 6
- Endoscopic treatment with biological fibrin glue may be effective in sealing fistulas that are resistant to conservative management 3
- Surgical treatment may be necessary in cases where conservative treatment fails or in cases of high-output fistulas with significant morbidity 4