What is the treatment for obstructive biliary disease?

Treatment of Obstructive Biliary Disease

The primary treatment for obstructive biliary disease is biliary decompression, with endoscopic retrograde cholangiopancreatography (ERCP) being the first-line therapeutic approach for most patients with biliary obstruction. 1, 2

Diagnostic Evaluation

• Initial assessment should include transabdominal ultrasound and liver function tests to confirm biliary dilation and identify potential causes 2
• Magnetic resonance cholangiopancreatography (MRCP) is recommended as a non-invasive option to explore the biliary tree when bile duct abnormalities are present 1, 3
• For moderate risk patients with suspected choledocholithiasis, MRCP or endoscopic ultrasound (EUS) should be performed with sensitivities of 93% and 95% respectively 4
• Computed tomography (CT) of the abdomen is less operator-dependent than ultrasound but involves radiation exposure 1

Treatment Algorithm Based on Etiology

1. Choledocholithiasis (Common Bile Duct Stones)

• ERCP with biliary sphincterotomy and stone extraction is the mainstay of therapy with 90% success rate 2, 4
• For large stones (>10-15 mm), lithotripsy or stone fragmentation techniques should be added 4
• If complete stone extraction is not possible during initial ERCP, temporary stenting followed by definitive treatment within 4-6 weeks is recommended 2
• Cholecystectomy should be performed following common bile duct clearance to prevent recurrence in patients with intact gallbladder 2
• For high surgical risk patients, biliary sphincterotomy and endoscopic duct clearance alone (without cholecystectomy) is an acceptable alternative 2

2. Malignant Biliary Obstruction

• For cholangiocarcinoma and other malignant causes, treatment depends on resectability 1
• For resectable tumors, surgical resection offers the best chance for long-term survival 1
• For unresectable disease, palliative biliary drainage via endoscopic stenting is preferred over surgical bypass 1
• Self-expandable metal stents (SEMS) are preferred over plastic stents for malignant obstruction due to longer patency 4, 5
• Liver transplantation is generally contraindicated for cholangiocarcinoma outside of clinical trials 1

3. Acute Cholangitis

• In acute cholangitis, urgent biliary decompression is lifesaving and should be performed promptly 1, 4
• ERCP is the treatment of choice for biliary decompression in patients with moderate/severe acute cholangitis 1
• Percutaneous transhepatic biliary drainage (PTBD) should be reserved for patients in whom ERCP fails 1
• Appropriate antimicrobial treatment is essential alongside biliary decompression 1

Special Considerations

• For patients with coagulopathy (INR >2.0 or platelet count <60K), endoscopic papillary balloon dilation without prior sphincterotomy using an 8mm diameter balloon should be considered 2
• For patients with moderate to massive ascites, endoscopic internal biliary catheter with removable plastic stent is recommended, avoiding percutaneous approaches due to risk of bleeding and ascitic fluid leakage 2
• In pregnancy, ERCP can be performed for urgent indications such as choledocholithiasis and cholangitis, ideally during the second trimester 4
• Ursodeoxycholic acid (8-10 mg/kg/day) may be considered for radiolucent gallstones but rarely leads to complete dissolution 6

Common Pitfalls and Caveats

• Routine biliary drainage before assessing resectability or preoperatively should be avoided except for specific clinical situations such as acute cholangitis 1
• Endoscopic sphincterotomy carries a 6-10% major complication rate, increasing to 19% in elderly patients with a mortality rate of 7.9% 4
• ERCP is associated with significant complications including pancreatitis (3-5%), bleeding (2% when combined with sphincterotomy), cholangitis (1%), and procedure-related mortality (0.4%) 1
• For patients with failed ERCP, alternative approaches include percutaneous transhepatic cholangiography (PTC) or combined percutaneous-endoscopic techniques 4