From the Guidelines
Biliary dilation size is considered significant when the common bile duct measures greater than 6-8 mm in diameter in adults with an intact gallbladder, and a dominant stricture is defined as a stenosis with a diameter of ≥ 1.5 mm in the common bile duct and/or ≥ 1.0 mm in a hepatic duct within 2 cm of the main hepatic confluence, as suggested by ESGE/EASL 1.
Key Considerations
- The definition of a dominant stricture is crucial in determining the clinical significance of biliary dilation, and it is essential to consider the clinical context and the presence of symptoms such as obstructive cholestasis and/or bacterial cholangitis 2.
- The size of the biliary dilation can vary depending on the individual and the presence of underlying pathology, and a high-grade biliary stricture on imaging in the common bile duct or hepatic ducts with signs or symptoms of obstructive cholestasis and/or bacterial cholangitis is a significant finding 2.
- The management of biliary obstruction favors an endoscopic approach, which is less invasive and can be performed as an outpatient procedure, and dilatation of biliary strictures is preferred over medical management alone as it improves symptoms and delays the need for orthotopic liver transplant 3.
Clinical Implications
- Persistent or progressive biliary dilation should prompt referral to gastroenterology or hepatobiliary specialists for further evaluation and management, and the decision to perform endoscopic intervention needs to be individualized and weighed against other treatment options such as liver transplantation 2.
- The rates of ERCP-related adverse events are higher among PSC patients than non-PSC patients, and it is essential to consider the complexity of the patient's disease and the potential risks and benefits of endoscopic intervention 3.
- A complete occlusion cholangiogram should generally be obtained if an ERCP is performed, as it adds little risk to the ERCP, decreases variability, and may reveal that a dominant stricture suspected at MRC is indeed not a stricture 1.
From the Research
Biliary Dilation Size
- The size of biliary dilation is an important factor in the management of biliary obstruction and bile duct injuries 4.
- A study found that dilation status of the bile duct before repair had no impact on short- or long-term outcomes in patients with bile duct injury 4.
- The study defined dilation as the presence of visible peripheral intrahepatic bile ducts with remaining bile duct diameter > 8 mm 4.
- Patients with non-dilated bile ducts had more severe bile duct injury than those with dilated bile ducts, but the rate of preoperative cholangitis was lower in patients with non-dilated bile ducts 4.
- The long-term anastomotic stricture rate was 5.7% with a mean follow-up period of 61.3 months, and there were no differences in long-term biliary complications according to dilation status 4.
Management of Biliary Obstruction
- Endoscopic retrograde cholangiopancreatography (ERCP) is a useful tool in the evaluation and management of acute pancreatitis and biliary obstruction 5, 6.
- ERCP with stent placement is a safe and effective method of biliary decompression in patients with cholangiocarcinoma and biliary obstruction 7.
- Percutaneous transhepatic biliary drainage (PTBD) is also a safe and effective method of biliary decompression in patients with cholangiocarcinoma and biliary obstruction 7.
- The choice of initial treatment approach depends on the center's experience and the patient's specific condition 5, 7.
Complications of Biliary Procedures
- Post-ERCP pancreatitis (PEP) is a potential complication of ERCP, but the risk can be reduced with endoscopic sphincterotomy (ES) in certain cases 8.
- ES was associated with a lower risk of PEP in patients undergoing biliary stenting for bile leak, but not in patients with distal bile duct obstruction with involvement of the pancreatic duct 8.