What is the recommended management for a mass compressing the common hepatic duct, causing biliary obstruction and mild intrahepatic biliary radical dilatation?

Management of Mass Compressing the Common Hepatic Duct with Biliary Obstruction

For a mass infiltrating and compressing the common hepatic duct causing biliary obstruction with mild intrahepatic biliary dilatation, endoscopic retrograde cholangiopancreatography (ERCP) with biliary stenting is the first-line treatment approach, with percutaneous transhepatic biliary drainage (PTBD) reserved for cases where ERCP fails or is not technically feasible. 1

Initial Diagnostic Workup

Before proceeding with intervention, obtain high-quality cross-sectional imaging (MRCP or contrast-enhanced CT) to:

• Determine the exact level and extent of biliary obstruction 1
• Assess for portal vein involvement or compression 2
• Identify the presence of hilar involvement versus mid-duct obstruction 1
• Evaluate for hepatic atrophy or isolated undrained segments 2

Antibiotic prophylaxis must be administered before any biliary drainage procedure to prevent cholangitis. 1

Primary Treatment Algorithm

For Mid-to-Distal Common Hepatic Duct Obstruction

ERCP with internal biliary stenting is the procedure of choice as first-line therapy. 1 The endoscopic approach offers:

• Lower invasiveness compared to percutaneous methods 1
• Avoidance of liver capsule violation and associated bleeding risk 1
• Ability to place internal stents without external drainage 1

Metal stents (fully or partially covered) are strongly preferred over plastic stents for malignant obstruction to reduce bile leak risk and provide longer patency. 1

For Hilar or High Bile Duct Obstruction

Percutaneous transhepatic biliary drainage is the preferred initial approach for obstruction at or above the biliary confluence. 1, 2 This is because:

• Interventional radiologists can selectively target specific hepatic segments for drainage 2
• Risk of introducing enteric contents into isolated undrained ducts is minimized 2
• Endoscopic access to high strictures is technically more challenging 1

A transhepatic approach is specifically recommended for hilar blocks per consensus guidelines. 1

Stent Selection and Placement Strategy

For endoscopic placement:

• Use a 19-gauge EUS-FNA needle for duct puncture 1
• Employ a 0.035 inch or 0.025 inch guidewire with floppy tip for bile duct negotiation 1
• Dilate the tract using catheters, balloons, or cystotomes (avoid precut papillotomes) 1

When placing stents above the ampulla (suprapapillary position), the sphincter of Oddi function is preserved, which may lower future cholangitis risk by preventing enteric contamination. 2

Special Clinical Scenarios

Coagulopathy (INR >2.0 or Platelets <60K)

Endoscopic internal biliary catheter with removable plastic stent is the appropriate procedure, as PTBD is contraindicated with uncorrected coagulopathy due to bleeding risk. 1 The percutaneous approach violates the liver capsule, which is the most common source of bleeding complications (occurring in approximately 2.5% of cases). 1

Moderate to Massive Ascites

Endoscopic biliary drainage is strongly preferred over percutaneous approaches. 1 PTBD is relatively contraindicated in the presence of significant ascites due to:

• Difficulty with initial duct access 1
• Risk of ascitic fluid leakage 1
• Higher complication rates 1

Failed ERCP

EUS-guided biliary drainage (EUS-BD) is recommended as the procedure of choice when ERCP fails, if expertise is available. 1 This represents a good alternative with high success rates, particularly when duodenal stenosis or altered anatomy precludes standard ERCP. 1

Tissue Diagnosis Considerations

Given the imaging description of a mass abutting the pancreas head with periportal lymphadenopathy, tissue diagnosis should be obtained during the drainage procedure when feasible. 2 This can be accomplished via:

• EUS-guided fine needle aspiration during EUS-BD 1
• Brush cytology during ERCP
• Percutaneous biopsy if PTBD is performed 2

Even when non-calculous material is found obstructing the bile duct without an obvious primary tumor, malignancy must be considered and material sent for pathological evaluation. 3

Post-Procedure Monitoring

Monitor for signs of:

• Stent occlusion (recurrent abdominal pain, jaundice) 4
• Cholangitis (fever, elevated white blood cell count) 1, 4
• Bile leak 1

Patients with acute cholangitis who fail to respond to antibiotic therapy or who have signs of septic shock require urgent biliary decompression within 24 hours. 1

Definitive Management Planning

Once biliary drainage is established and tissue diagnosis obtained:

• Surgical resection should be evaluated if the mass is resectable 2
• Chemotherapy planning requires adequate bilirubin reduction 2
• For unresectable malignancy, long-term metal stent placement provides better palliation than plastic stents 1

Multidisciplinary support including interventional radiology, surgery, and anesthesiology is recommended in centers performing complex biliary drainage procedures. 1