From the Guidelines
The management of chronic left upper quadrant pain with biliary sludge, mid common bile duct (CBD) dilation, distal CBD stricture, and normal liver function tests (LFTs) should prioritize endoscopic retrograde cholangiopancreatography (ERCP) with endoscopic dilatation with or without stenting as the initial approach. This recommendation is based on the guidelines for the diagnosis and management of primary sclerosing cholangitis, which suggest that in patients with dominant strictures, initial management with endoscopic dilatation with or without stenting is recommended 1.
Key Considerations
- The presence of a distal CBD stricture and mid CBD dilation on imaging studies such as CT and MRCP, even with normal LFTs, warrants further investigation to exclude a dominant stricture or malignancy.
- ERCP allows for both diagnostic visualization of the stricture and therapeutic intervention, including the potential for stent placement to relieve obstruction.
- Prior to endoscopic therapy, brush cytology and/or endoscopic biopsy should be performed to exclude a superimposed malignancy 1.
Therapeutic Approach
- Endoscopic dilatation with or without stenting is the recommended initial management for dominant strictures, as it can provide relief from obstruction and improve biliary drainage.
- The use of ursodeoxycholic acid (10-15mg/kg/day) may help in mobilizing biliary sludge, and pain control with acetaminophen or NSAIDs is appropriate, with caution against the use of opioids due to their potential effect on the sphincter of Oddi function.
- Prophylactic antibiotics should be considered before the procedure to reduce the risk of infection, and post-procedure monitoring for complications such as pancreatitis is essential.
From the Research
Management of Chronic LUQ Pain with Sludge on CT and MRCP
- The patient presents with chronic left upper quadrant (LUQ) pain, sludge on CT and MRCP, mid common bile duct (CBD) dilation, and distal CBD stricture, with normal liver function tests (LFTs) 2, 3.
- The management of this condition involves the treatment of the underlying cause of the CBD stricture, which may be benign or malignant in nature.
Diagnostic Approach
- The use of multiplanar reformations and 3D imaging can aid in the evaluation of abnormalities involving the distal CBD and ampulla, and can help to suggest the presence of malignancy 4.
- A systematic approach to CT evaluation is necessary to avoid missed diagnoses, especially in the setting of unexplained biliary ductal dilatation.
Treatment Options
- Endoscopic therapy by balloon dilation and placement of multiple large-bore plastic stents is the treatment of choice for benign biliary stricture 2.
- The use of fully covered self-expandable metal stents (CSEMS) may be appropriate in highly selected conditions, such as refractory benign biliary stricture, despite multiple plastic stent placement or difficult to treat bile duct stricture from chronic pancreatitis 2.
- Percutaneous transhepatic papillary balloon dilation (PTPBD) may be a viable alternative to ERCP for CBD stone removal, especially in patients with low cardiopulmonary reserve or anatomic abnormalities of the upper GI tract 5.
Considerations
- The technical success rate and incidence of complications should be considered when choosing a treatment option, with PTPBD showing a similar technical success rate and fewer perioperative complications compared to ERCP 5.
- The potential risks and benefits of each treatment option should be carefully evaluated, including the risk of cholecystitis, stent migration, infection, and pancreatitis associated with CSEMS placement 2.