What is the management of a 47-year-old patient with chronic left upper quadrant (LUQ) pain, sludge on computed tomography (CT) and magnetic resonance cholangiopancreatography (MRCP) showing mid common bile duct (CBD) dilation and distal CBD stricture, with normal liver function tests (LFTs) and possible choledochal cyst?

From the Guidelines

For a 47-year-old patient with chronic left upper quadrant pain, biliary sludge on CT, mid-CBD dilation with distal stricture on MRCP, and normal liver function tests, the recommended management would be to proceed with ERCP (Endoscopic Retrograde Cholangiopancreatography) as it is the most recent and highest quality approach for managing biliary obstruction, as suggested by the 2019 study 1. This procedure would serve both diagnostic and therapeutic purposes. During ERCP, the stricture can be evaluated, tissue samples obtained if needed, and the stricture can be dilated with balloon dilation or stent placement. If a choledochocele (cystic dilation of the distal common bile duct) is confirmed, endoscopic sphincterotomy would be appropriate to facilitate drainage. Some key points to consider in the management of this patient include:

• The patient's presentation suggests biliary obstruction, which requires intervention despite normal liver function tests, as these findings can progress to more severe biliary disease if left untreated.
• ERCP is the most commonly performed invasive diagnostic and therapeutic biliary procedure, with a high success rate for clearing CBD stones and managing distal CBD strictures, as noted in the 2019 study 1.
• Prior to ERCP, a complete blood count, coagulation profile, and cross-matching of blood should be performed, and the patient should fast for at least 8 hours before the procedure and receive appropriate sedation.
• Prophylactic antibiotics (typically a single dose of a broad-spectrum antibiotic like ciprofloxacin 400mg IV or ceftriaxone 1g IV) should be administered before the procedure to prevent cholangitis, as recommended by the 2019 study 1.
• Following ERCP, the patient should be monitored for complications such as pancreatitis, bleeding, or perforation, and long-term management may include regular follow-up imaging to ensure resolution of the stricture and to monitor for recurrence. The 2021 study 1 also supports the use of ERCP as the first-line approach for managing benign biliary strictures, with a success rate ranging from 74 to 90%, and notes that temporary placement of multiple plastic stents over a long period of time is the preferred treatment. Overall, the recommended approach is to proceed with ERCP, as it is the most effective and efficient way to manage the patient's biliary obstruction and prevent potential complications, as supported by the 2019 study 1 and the 2021 study 1.

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 showing mid CBD dilation and distal CBD stricture, and normal liver function tests (LFTs) 2, 3.
• The management of this condition is ambiguous, but a pragmatic approach can be taken based on the patient's symptoms and imaging results 3.
• Endoscopic ultrasound (EUS) can be used to evaluate the CBD dilatation, especially when index imaging is normal, to avoid unnecessary MRCP and ERCP 2.

Diagnostic Approach

• The diagnostic approach for suspected malignant bile duct strictures can include percutaneous transhepatic cholangiography (PTC) and endoscopic retrograde cholangiography (ERCP) with brush cytology and forceps biopsy 4.
• PTC and ERCP have good diagnostic sensitivity and accuracy, but PTC may be preferable for strictures located at the hilum due to its higher sensitivity and accuracy 4.
• MRCP can be used to diagnose acute and chronic biliary disorders, providing an excellent anatomic overview and functional information about the hepatobiliary system 5.

Treatment Options

• For patients with dilated CBD and normal LFTs without apparent cause, conservative management may be appropriate, as the condition is mostly benign and of no consequence 3.
• Endoscopic sphincterotomy and stone extraction can be performed for patients with choledocholithiasis, and the CBD diameter can be monitored for normalization 6.
• Asymptomatic CBD dilation may persist in a minority of patients after removal of CBD stones, but it can be attributed to retained choledocholithiasis within the first month if associated with symptoms and abnormal LFTs 6.