Inflammatory biliary stenosis
What is it?
By "stenosis" we mean the "closure/obstruction" of the bile duct, and this can originate from alterations within the bile lumen (stones, or endoprosthesis previously placed and obstructed, or more rarely clots, infections or other migrated foreign bodies such as embolizing coils), from the duct itself (as in the case of neoplastic or inflammatory stenosis), or from extrinsic compression (outside this). A further fundamental distinction is made between stenosis of benign or malignant origin: inflammatory or benign stenosis are defined as such once the malignant etiology has been excluded by invasive or non-invasive techniques.
Benign causes of extrinsic biliary compression include Mirizzi syndrome (in which gallstones compress and obliterate the biliary tract), chronic pancreatitis (in which inflammation of the pancreas closes off the biliary tract as it passes through the pancreatic gland), cysts (hepatic, pancreatic, or choledochal), and vascular abnormalities (portal cholangiopathy).
Inflammatory biliary stenoses originating in the duct wall primarily include autoimmune (including primary biliary cholangitis and IgG4 disease), traumatic (from inveterate choledocholithiasis), and iatrogenic (cholecystectomy or liver transplantation outcomes) diseases.
Which are the symptoms?
The clinical spectrum of inflammatory biliary tract stenosis is highly variable and closely related to the underlying pathology. Among the most frequent clinical presentations we find jaundice (yellowish discoloration of skin and mucous membranes due to accumulation of bilirubin in tissues), which may or may not be associated with abdominal pain, fever or itching. Symptoms such as asthenia, general malaise, and weight loss may suggest a malignant etiology, while the patient's medical history plays a crucial role in the diagnostic algorithm, providing clues to the underlying etiology.
- Abdominal pain
- General malaise
How is it diagnosed?
The initial approach to the patient with biliary stenosis includes non-invasive imaging methods and blood chemistry testing. The first level imaging exam is transabdominal ultrasound. Non-invasive second level radiological examinations include CT and cholangio-magnetic resonance (CMR) but also Echo-endoscopy, especially depending on the Center referred to and therefore the expertise of the place.
In recent years, there has been a gradual increase in endoscopic methods in both the diagnosis and therapy of these diseases.
Nowadays endoscopic retrograde cholangiopancreatography (ERCP) is used almost exclusively for therapeutic purposes, but in inflammatory and non-inflammatory biliary stenosis it can also be used for diagnostic purposes, but always after the other methods (CT, MRI and EUS), thanks to the development of innovative additional methods such as cytology with brushing and cholangioscopy with biopsies. These investigations guarantee not only greater diagnostic accuracy, but also the possibility of a direct view of the biliary tract, greater accuracy in tissue sampling and a low incidence of intra- and post-procedural adverse events.
How is it treated?
Treatment of inflammatory biliary strictures is based on resolution of the underlying pathology. Given the multiplicity of potential causes, treatment options are extremely variable. The conservative approach is reserved for cases in which the biliary stenosis does not affect alterations in the clinical and / or biochemical picture of the patient. Medical therapy is used most frequently in autoimmune diseases, such as SPC and IgG4-related disease, or infectious diseases.
The endoscopic approach varies depending on the underlying condition, from removal of gallstones by ERCP, their crushing during cholangioscopy, to placement of plastic or metal prostheses to ensure adequate biliary drainage.
Surgery is reserved for cases in which the treatments listed above fail to provide sufficient resolution or palliation of the biliary obstruction. It includes more or less complex interventions, from bilio-digestive shunts to liver transplantation.
Where do we treat it?
Are you interested in receiving the treatment?