What are the causes and treatments of hepatic ductal dilation?

From the Guidelines

Hepatic ductal dilation is primarily caused by obstructions in the bile ducts, with common causes including gallstones, tumors, strictures from prior surgery, primary sclerosing cholangitis, and parasitic infections. The treatment of hepatic ductal dilation depends on the underlying cause, with the goal of relieving the obstruction, preventing infection, and addressing the underlying cause.

Causes of Hepatic Ductal Dilation

• Gallstones: a common cause of bile duct obstruction, which can be treated with endoscopic retrograde cholangiopancreatography (ERCP) with stone extraction and possible sphincterotomy 1
• Tumors: such as cholangiocarcinoma or pancreatic cancer, which may require stent placement via ERCP or percutaneous transhepatic cholangiography (PTC) to restore bile flow, followed by appropriate cancer treatment
• Strictures from prior surgery: which may require surgical interventions such as hepaticojejunostomy
• Primary sclerosing cholangitis: which is managed with ursodeoxycholic acid (13-15mg/kg/day) 1
• Parasitic infections: such as liver flukes, which require antiparasitic medications like praziquantel (25mg/kg three times daily for 1-2 days)

Treatment of Hepatic Ductal Dilation

• Endoscopic internal biliary catheter with a removable plastic stent is usually appropriate as an initial therapeutic procedure for patients with dilated bile ducts from choledocholithiasis 1
• Malignant obstructions may require stent placement via ERCP or PTC to restore bile flow, followed by appropriate cancer treatment
• Antibiotics like piperacillin-tazobactam (3.375g IV every 6 hours) or ciprofloxacin (400mg IV twice daily) are necessary when cholangitis is present
• Surgical interventions such as hepaticojejunostomy may be needed for benign strictures
• Prompt diagnosis using ultrasound, CT, MRI/MRCP, or ERCP is essential, as untreated biliary obstruction can lead to cholangitis, liver damage, and potentially life-threatening complications. The most recent and highest quality study, 1, provides guidance on the radiologic management of biliary obstruction, including the use of endoscopic internal biliary catheter with a removable plastic stent as an initial therapeutic procedure for patients with dilated bile ducts from choledocholithiasis. In addition, 1 provides recommendations for the management of primary sclerosing cholangitis, including the use of ursodeoxycholic acid and endoscopic treatment with concomitant ductal sampling for suspected significant strictures. Overall, the treatment of hepatic ductal dilation should be individualized based on the underlying cause and the patient's specific needs, with the goal of relieving the obstruction, preventing infection, and addressing the underlying cause.

From the Research

Causes of Hepatic Ductal Dilation

• Hepatolithiasis, which is prevalent in south-east Asia, can cause intrahepatic strictures and ductal angulation, leading to hepatic ductal dilation 2
• Biliary cystadenoma can also cause bilateral intrahepatic bile duct dilatation, as seen in a case report where a patient presented with epigastric pain and a voluminous cystic lesion of the left hepatic lobe 3
• Solitary cystic dilation of intrahepatic bile ducts can occur without extrahepatic biliary anomalies or renal lesions, and may be associated with bile stasis and mucous hypersecretion 4
• Common bile-duct dilatation can also occur in patients without biliary symptoms or causative lesions on ultrasonography, and may be associated with juxtapapillary duodenal diverticulum, benign stricture, or other lesions 5
• Disparate dilatation of the intrahepatic and extrahepatic bile ducts can occur in surgical jaundice, where the extrahepatic biliary system is increased in caliber despite a normal appearance of the intrahepatic ducts 6

Treatments of Hepatic Ductal Dilation

• Postoperative ductal dilatation and stenting, combined with endoscopic electrohydraulic lithotripsy, can be an effective and safe treatment for complicated residual hepatolithiasis with biliary stricture 2
• Left hepatectomy may be necessary for the treatment of biliary cystadenoma with pseudo-ovarian stroma and pedunculated intraductal extension to the biliary convergence 3
• Further diagnostic study, such as endoscopic retrograde cholangiopancreatography (ERCP) or computed tomography (CT), may be helpful for the early diagnosis of biliary tract disease in patients with common bile-duct dilatation without biliary symptoms or causative lesions on ultrasonography 5