What is the management approach for a patient with a benign common bile duct (CBD) stricture, possibly related to a passed stone?

Management of Benign CBD Stricture

Endoscopic therapy with temporary placement of multiple plastic stents over a prolonged period is the first-line treatment for benign CBD strictures, achieving success rates of 74-90%, though recurrence occurs in up to 30% of patients within 2 years of stent removal. 1

Etiology: Can a Passed Stone Cause Stricture?

Yes, a passed stone can absolutely cause benign CBD stricture through several mechanisms:

• Stone-related trauma: Stones can cause direct injury to the bile duct wall during passage, leading to inflammation, fibrosis, and subsequent stricture formation 2, 3
• Perforation and inflammation: Stone perforation through the duct wall triggers intense inflammatory response and scarring 3
• Chronic obstruction: Long-standing stones cause upstream inflammation and fibrosis even after passage 2
• Secondary biliary cirrhosis: Untreated or recurrent stone-related strictures can progress to secondary biliary cirrhosis if left unmanaged 2

Initial Diagnostic Approach

Trans-abdominal ultrasound and liver function tests are recommended as initial evaluation, but normal results do not exclude stricture if clinical suspicion remains high. 1

• Look specifically for: biliary dilation, wall thickening, jaundice, elevated alkaline phosphatase and bilirubin 1, 4
• Advanced imaging with MRCP or EUS is indicated when initial tests are inconclusive but suspicion persists 1, 5
• ERCP provides both diagnostic visualization and therapeutic intervention 1

First-Line Endoscopic Management

Multiple plastic stent placement is the preferred initial treatment strategy:

• Stent protocol: Place multiple plastic stents (typically 2-4) to maximize dilation of the stricture 1
• Duration: Stents remain in place for 4-8 weeks initially, with serial exchanges every 3 months 1
• Total treatment duration: Continue stenting for 12 months or longer to achieve optimal long-term patency 1
• Success rates: 74-90% initial success, but 30% recurrence within 2 years after stent removal 1

For strictures >2 cm from the hepatic confluence, fully covered self-expanding metal stents (SEMS) are an alternative to plastic stents. 1

When Strictures Are Recognized Early

• Early post-injury strictures (recognized within weeks of the inciting event) respond more favorably to endoscopic treatment than delayed fibrotic strictures 1
• These are often associated with bile leak and respond better because fibrosis is less established 1
• Aggressive early treatment prevents progression to dense fibrotic strictures 1

Follow-Up Protocol

Structured surveillance is essential given the 30% recurrence rate:

• During stenting: ERCP with cholangiography every 3 months for stent exchange 1
• After stent removal: Repeat cholangiography at stent removal to confirm resolution 1
• Post-treatment surveillance: Monitor liver function tests every 3-6 months for the first 2 years 1
• Clinical monitoring: Watch for recurrent symptoms (jaundice, cholangitis, right upper quadrant pain) that suggest re-stricturing 4
• Imaging if symptomatic: Obtain MRCP or repeat ERCP if liver enzymes rise or symptoms recur 1, 5

Alternative Approaches When ERCP Fails

Percutaneous transhepatic biliary drainage (PTBD) is the next option when endoscopic access fails:

• Technical success rate of 90% in expert centers 1
• Short-term clinical success of 70-80% 1
• Particularly useful for complete obstructions with sepsis 1
• Can be more difficult with non-dilated ducts but still achievable 1

Surgical Management

Surgery is reserved for endoscopic failures or complex strictures:

• Roux-en-Y hepaticojejunostomy is the definitive surgical repair for refractory strictures 1
• Referral to a hepatobiliary surgeon is essential—non-specialist repairs have higher failure rates 1
• Surgical repair shows superior 5-year outcomes when performed by experienced HPB surgeons 1

Critical Pitfalls to Avoid

• Don't stop surveillance after stent removal: The 30% recurrence rate within 2 years means ongoing monitoring is mandatory 1
• Don't delay treatment: Untreated strictures can progress to secondary biliary cirrhosis and liver failure 2
• Don't attempt surgical repair without HPB expertise: Non-specialist repairs have significantly higher morbidity and mortality 1
• Don't assume normal LFTs exclude stricture: Maintain high clinical suspicion even with normal labs if symptoms suggest biliary obstruction 1, 4
• Don't use stenting as definitive treatment in young, healthy patients: Consider surgical repair for better long-term outcomes in appropriate candidates 1

Special Consideration: Recurrent Stone Formation

• Post-cholecystectomy patients with strictures are at risk for primary stone formation within the strictured segment 6
• Stone extraction should be performed before or concurrent with stricture dilation 1, 6
• Address both the stricture and any stones to prevent recurrent cholangitis 1, 4