Bile Duct Strictures

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Background

Bile duct stricture (biliary stricture) is an uncommon but challenging clinical condition that requires a coordinated multidisciplinary approach involving gastroenterologists, radiologists, and surgical specialists. Unfortunately, most benign bile duct strictures (biliary strictures) are iatrogenic, resulting from operative trauma (see images below).[1] Bile duct strictures (biliary strictures) may be asymptomatic but, if ignored, can cause life-threatening complications, such as ascending cholangitis,[2, 3] liver abscess, and secondary biliary cirrhosis.


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Focal intrahepatic benign bile duct stricture after cholecystectomy.


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Percutaneous transhepatic cholangiogram with balloon dilation of a postoperative bile duct stricture.

However, not all bile duct strictures (biliary strictures) are benign. Pancreatic cancer is the most common cause of malignant biliary strictures (see images below).[4, 5] Most of these patients die of complications of tumor invasion and metastasis rather than from the bile duct stricture (biliary stricture) per se. Nonetheless, both benign and malignant bile duct strictures can be associated with distressing symptoms and excessive morbidity.[6]


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Endoscopic retrograde cholangiopancreatographic cholangiogram demonstrating an isolated mid-hepatic duct stricture as a result of pancreatic cancer.


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Focal bile duct stricture as a result of pancreatic cancer in the head of the pancreas.

For excellent patient education resources, visit eMedicineHealth's Digestive Disorders Center and Infections Center. Also, see eMedicineHealth's patient education articles Cirrhosis and Gallstones.

Pathophysiology

Strictures of the bile duct can be benign or malignant. Benign strictures develop when the bile ducts are injured in some way. The injury may be a single acute event, such as damage to the bile ducts during surgery or trauma to the abdomen; a recurring condition, such as pancreatitis or bile duct stones; or a chronic disease, such as primary sclerosing cholangitis (PSC). After the injury, an inflammatory response ensues, which is followed by collagen deposition, fibrosis, and narrowing of the bile duct lumen (see images below).


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Endoscopic retrograde cholangiopancreatographic cholangiogram of a solitary benign stricture of the distal bile duct. Resection demonstrated sclerosin....


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Endoscopic retrograde cholangiopancreatographic cholangiogram demonstrating diffuse stricturing of the intrahepatic ducts that is consistent with prim....


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Periductal onion skin fibrosis seen in primary sclerosing cholangitis.


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Periductal lymphocytic and plasma cell infiltrate that is consistent with autoimmune cholangiopathy.

Depending on the nature of the insult, bile duct strictures (biliary strictures) can be single or multiple. Atrophy of the hepatic segment or lobe drained by the involved bile ducts, associated with hypertrophy of the unaffected segments, can occur, especially with chronic high-grade strictures. These changes can eventually progress to secondary biliary cirrhosis and portal hypertension.

Malignant strictures are usually the result of either a primary bile duct cancer (ie, causing a narrowing of the bile duct lumen and obstructing the flow of bile) or extrinsic compression of the bile ducts by a neoplasm in an adjacent organ, such as the gallbladder, pancreas, or liver (see image below).


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Endoscopic retrograde cholangiopancreatographic cholangiogram demonstrating a long bile duct stricture that represents external compression by gallbla....

Epidemiology

Frequency

United States

Although quite uncommon, the exact prevalence of bile duct strictures (biliary strictures) is unknown. One major category of bile duct strictures is postoperative bile duct stricture, which usually occurs as a result of a technical mishap during cholecystectomy, causing bile duct injury. Data from many large series of patients in the United States have revealed that the incidence rate of major bile duct injury is 0.2-0.3% after open cholecystectomy and 0.4-0.6% after a laparoscopic cholecystectomy.

International

Data from Europe have shown a similar rate to the United States of occurrence of postoperative bile duct strictures.

Mortality/Morbidity

Sex

History

Physical

Causes

Bile duct strictures (biliary strictures) can be benign or malignant, described as follows:

Laboratory Studies

Imaging Studies

Other Tests

Procedures

Histologic Findings

Surgically resected segments of the biliary tree will show the etiology of the bile duct stricture. In benign lesions the involved segment of the bile duct is surrounded by a collar of fibrosis causing a narrowing of the lumen (see image below). This is accompanied by a variable amount of inflammatory cellular infiltrate comprising a mixture of neutrophils, lymphocytes, plasma cells, and eosinophils. The mucosa of the strictured segment usually is atrophic, with areas of squamous metaplasia.


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Periductal onion skin fibrosis seen in primary sclerosing cholangitis.

In cholangiocarcinoma, there will be evidence of adenocarcinoma in the cross-sectional histology of the bile duct. In contrast, in autoimmune disease, the hallmark finding is dense lymphocytic infiltration (see image below).


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Periductal lymphocytic and plasma cell infiltrate that is consistent with autoimmune cholangiopathy.

Staging

Staging systems have been developed for bile duct strictures (biliary strictures) due to operative trauma, cholangiocarcinoma, and HIV disease. The choice of operative repair of a bile duct stricture depends on the location of the stricture. Strictures involving the CBD and low common hepatic duct are easier to repair compared with strictures that are more proximal.

Medical Care

Medical treatment consists of managing complications of bile duct strictures until definitive therapy can be instituted. Most patients who present with cholangitis have a response to antibiotics and supportive management. Patients who are elderly and frail and those presenting with hypotension or altered mental status are best treated in an intensive care unit.

Surgical Care

Patients with cholangitis whose conditions fail to improve with conservative treatment usually require urgent decompression of the obstructed biliary system. Treatment options for bile duct strictures (biliary strictures) include (1) endoscopic or percutaneous balloon dilatation and insertion of an endoprosthesis or (2) surgery.

Consultations

Diet

Activity

Medication Summary

The goals of pharmacotherapy iin those with bile duct strictures (biliary strictures) are to eradicate the infection, prevent complications, and reduce morbidity.

Piperacillin and tazobactam sodium (Zosyn)

Clinical Context:  Antipseudomonal penicillin plus beta-lactamase inhibitor. Inhibits biosynthesis of cell wall mucopeptide and is effective during stage of active multiplication.

Imipenem and cilastatin (Primaxin)

Clinical Context:  For the treatment of multiple-organism infections in which other agents do not have broad-spectrum coverage or are contraindicated due to potential toxicity.

Metronidazole (Flagyl, Protostat)

Clinical Context:  Imidazole ring-based antibiotic active against various anaerobic bacteria and protozoa. Used in combination with other antimicrobial agents (except for Clostridium difficile enterocolitis).

Gentamicin (Garamycin, Gentacidin)

Clinical Context:  Aminoglycoside antibiotic for gram-negative coverage. Used in combination with both an agent against gram-positive organisms and one that covers anaerobes.

Not the DOC. Consider if penicillins or other less toxic drugs are contraindicated, when clinically indicated, and in mixed infections caused by susceptible staphylococci and gram-negative organisms.

Dosing regimens are numerous; adjust the dose based on CrCl and changes in volume of distribution. May be given IV/IM.

Penicillin G (Pfizerpen)

Clinical Context:  Interferes with synthesis of cell wall mucopeptide during active multiplication, resulting in bactericidal activity against susceptible microorganisms.

Class Summary

Empiric antimicrobial therapy must be comprehensive and should cover all likely pathogens in the context of this clinical setting.

Further Inpatient Care

Further Outpatient Care

Transfer

Complications

Prognosis

Author

William R Brugge, MD, Professor of Medicine, Harvard Medical School; Director, Gastrointestinal Endoscopy Unit, Massachusetts General Hospital

Disclosure: RedPath Grant/research funds Consulting

Coauthor(s)

Ashraf Saleemuddin, MD, Fellow, Department of Gastroenterology, Boston University Medical Center

Disclosure: Nothing to disclose.

Hemant Pande, MD, Consulting Staff, Department of Gastroenterology, Leesville Surgical Clinic and Digestive Disease Center

Disclosure: Nothing to disclose.

Lawrence J Cheskin, MD, Director, Johns Hopkins Weight Management Center; Associate Professor, Health, Behavior & Society, Johns Hopkins Bloomberg School of Public Health; Joint Appointment, Department of Medicine, Division of Gastroenterology, Johns Hopkins University School of Medicine; International Health/Human Nutrition, JH Bloomberg School of Public Health

Disclosure: Medifast Salary Consulting; Medifast Consulting fee Consulting; Vivus Consulting fee National Advisory Board member; Vivus None purchase of stock as an investment; Medifast None purchase of stock as an investment

Parviz Nikoomanesh, MD, Clinical Director of Gastroenterology, Director of Endoscopy, Associate Professor, Department of Internal Medicine, Bayview Medical Center, Johns Hopkins University School of Medicine

Disclosure: Nothing to disclose.

Specialty Editors

David Greenwald, MD, Associate Professor of Clinical Medicine, Fellowship Program Director, Department of Medicine, Division of Gastroenterology, Montefiore Medical Center, Albert Einstein College of Medicine

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

James L Achord, MD, Professor Emeritus, Department of Medicine, Division of Digestive Diseases, University of Mississippi School of Medicine

Disclosure: Nothing to disclose.

Alex J Mechaber, MD, FACP, Senior Associate Dean for Undergraduate Medical Education, Associate Professor of Medicine, University of Miami Miller School of Medicine

Disclosure: Nothing to disclose.

Chief Editor

Julian Katz, MD, Clinical Professor of Medicine, Drexel University College of Medicine

Disclosure: Nothing to disclose.

References

  1. Vecchio R, Ferrara M, Pucci L, Meli G, Latteri S. [Treatment of iatrogenic lesions of the common bile duct] [Italian]. Minerva Chir. Jan-Feb 1995;50(1-2):29-38. [View Abstract]
  2. Hanau LH, Steigbigel NH. Acute (ascending) cholangitis. Infect Dis Clin North Am. Sep 2000;14(3):521-46. [View Abstract]
  3. Hastier P, Buckley JM, Peten EP, Dumas R, Delmont J. Long term treatment of biliary stricture due to chronic pancreatitis with a metallic stent. Am J Gastroenterol. Jul 1999;94(7):1947-8. [View Abstract]
  4. Deviere J, Cremer M, Baize M, Love J, Sugai B, Vandermeeren A. Management of common bile duct stricture caused by chronic pancreatitis with metal mesh self expandable stents. Gut. Jan 1994;35(1):122-6. [View Abstract]
  5. Kamisawa T, Tu Y, Egawa N, et al. Involvement of pancreatic and bile ducts in autoimmune pancreatitis. World J Gastroenterol. Jan 28 2006;12(4):612-4. [View Abstract]
  6. Magistrelli P, Masetti R, Coppola R, et al. Changing attitudes in the palliation of proximal malignant biliary obstruction. J Surg Oncol Suppl. 1993;3:151-3. [View Abstract]
  7. Klein AS, Savader S, Burdick JF, et al. Reduction of morbidity and mortality from biliary complications after liver transplantation. Hepatology. Nov 1991;14(5):818-23. [View Abstract]
  8. Orons PD, Sheng R, Zajko AB. Hepatic artery stenosis in liver transplant recipients: prevalence and cholangiographic appearance of associated biliary complications. AJR Am J Roentgenol. Nov 1995;165(5):1145-9. [View Abstract]
  9. Mosca S, Militerno G, Guardascione MA, et al. Late biliary tract complications after orthotopic liver transplantation: diagnostic and therapeutic role of endoscopic retrograde cholangiopancreatography. J Gastroenterol Hepatol. Jun 2000;15(6):654-60. [View Abstract]
  10. Pozsar J, Sahin P, Laszlo F, Topa L. Endoscopic treatment of sphincterotomy-associated distal common bile duct strictures by using sequential insertion of multiple plastic stents. Gastrointest Endosc. Jul 2005;62(1):85-91. [View Abstract]
  11. Schwartz DA, Petersen BT, Poterucha JJ, Gostout CJ. Endoscopic therapy of anastomotic bile duct strictures occurring after liver transplantation. Gastrointest Endosc. Feb 2000;51(2):169-74. [View Abstract]
  12. Cherqui D, Palazzo L, Piedbois P, et al. Common bile duct stricture as a late complication of upper abdominal radiotherapy. J Hepatol. Jun 1994;20(6):693-7. [View Abstract]
  13. Nakakubo Y, Kondo S, Katoh H, Shimizu M. Biliary stricture as a possible late complication of radiation therapy. Hepatogastroenterology. Nov-Dec 2000;47(36):1531-2. [View Abstract]
  14. Cello JP. Human immunodeficiency virus-associated biliary tract disease. Semin Liver Dis. May 1992;12(2):213-8. [View Abstract]
  15. Nash JA, Cohen SA. Gallbladder and biliary tract disease in AIDS. Gastroenterol Clin North Am. Jun 1997;26(2):323-35. [View Abstract]
  16. Colonna JO 2nd, Shaked A, Gomes AS, Colquhoun SD, Jurim O, McDiarmid SV, et al. Biliary strictures complicating liver transplantation. Incidence, pathogenesis, management, and outcome. Ann Surg. Sep 1992;216(3):344-50; discussion 350-2. [View Abstract]
  17. Liver Transplantation. Posttransplant biliary complications in the pre- and post-model for end-stage liver disease era. Apr 2011;17(4):428-35. [View Abstract]
  18. Fan ST, Ng IO, Choi TK, Lai EC. Tuberculosis of the bile duct: a rare cause of biliary stricture. Am J Gastroenterol. Apr 1989;84(4):413-4. [View Abstract]
  19. Patel AH, Harnois DM, Klee GG, LaRusso NF, Gores GJ. The utility of CA 19-9 in the diagnoses of cholangiocarcinoma in patients without primary sclerosing cholangitis. Am J Gastroenterol. Jan 2000;95(1):204-7. [View Abstract]
  20. Lempinen M, Isoniemi H, Makisalo H, et al. Enhanced detection of cholangiocarcinoma with serum trypsinogen-2 in patients with severe bile duct strictures. J Hepatol. Nov 2007;47(5):677-83. [View Abstract]
  21. Stavropoulos S, Larghi A, Verna E, Battezzati P, Stevens P. Intraductal ultrasound for the evaluation of patients with biliary strictures and no abdominal mass on computed tomography. Endoscopy. Aug 2005;37(8):715-21. [View Abstract]
  22. Best Evidence: Nandalur KR, Hussain HK, Weadock WJ, et al. Possible biliary disease: diagnostic performance of high-spatial-resolution isotropic 3D T2-weighted MRCP. Radiology. Dec 2008;249(3):883-90. [View Abstract]
  23. Mansfield JC, Griffin SM, Wadehra V, Matthewson K. A prospective evaluation of cytology from biliary strictures. Gut. May 1997;40(5):671-7. [View Abstract]
  24. Kipp BR, Stadheim LM, Halling SA, et al. A comparison of routine cytology and fluorescence in situ hybridization for the detection of malignant bile duct strictures. Am J Gastroenterol. Sep 2004;99(9):1675-81. [View Abstract]
  25. [Best Evidence] Best Evidence: Gong Y, Huang ZB, Christensen E, Gluud C. Ursodeoxycholic acid for primary biliary cirrhosis. Cochrane Database Syst Rev. Jul 16 2008;CD000551. [View Abstract]
  26. [Best Evidence] Best Evidence: Mahid SS, Jafri NS, Brangers BC, et al. Meta-analysis of cholecystectomy in symptomatic patients with positive hepatobiliary iminodiacetic acid scan results without gallstones. Arch Surg. Feb 2009;144(2):180-7. [View Abstract]
  27. [Best Evidence] Best Evidence: Olsen JC, McGrath NA, Schwarz DG, Cutcliffe BJ, Stern JL. A double-blind randomized clinical trial evaluating the analgesic efficacy of ketorolac versus butorphanol for patients with suspected biliary colic in the emergency department. Acad Emerg Med. Aug 2008;15(8):718-22. [View Abstract]
  28. Bismuth H, Nakache R, Diamond T. Management strategies in resection for hilar cholangiocarcinoma. Ann Surg. Jan 1992;215(1):31-8. [View Abstract]
  29. Bjornsson E, Lindqvist-Ottosson J, Asztely M, Olsson R. Dominant strictures in patients with primary sclerosing cholangitis. Am J Gastroenterol. Mar 2004;99(3):502-8. [View Abstract]
  30. Yoon WJBrugge WR. Endoscopic evaluation of bile duct strictures. Gastrointest Endosc Clin N Am. April 2013;23(2):277-93. [View Abstract]
  31. Bueno JT, Gerdes H, Kurtz RC. Endoscopic management of occluded biliary Wallstents: a cancer center experience. Gastrointest Endosc. Dec 2003;58(6):879-84. [View Abstract]
  32. Frattaroli FM, Reggio D, Guadalaxara A, Illomei G, Pappalardo G. Benign biliary strictures: a review of 21 years of experience. J Am Coll Surg. Nov 1996;183(5):506-13. [View Abstract]
  33. Gibbons JC, Williams SJ. Progress in the endoscopic management of benign biliary strictures. J Gastroenterol Hepatol. Feb 1998;13(2):116-24. [View Abstract]
  34. Ishizuka D, Shirai Y, Hatakeyama K. Ischemic biliary stricture due to lymph node dissection in the hepatoduodenal ligament. Hepatogastroenterology. Nov-Dec 1998;45(24):2048-50. [View Abstract]
  35. Itani KM, Taylor TV. The challenge of therapy for pancreatitis-related common bile duct stricture. Am J Surg. Dec 1995;170(6):543-6. [View Abstract]
  36. Kadir S, White RI Jr. Biliary stricture dilatation: multicenter review of clinical management in 73 patients. Radiology. Jan 1987;162(1 pt 1):286. [View Abstract]
  37. Kim KH, Sung CK, Park BG, et al. Clinical significance of intrahepatic biliary stricture in efficacy of hepatic resection for intrahepatic stones. J Hepatobiliary Pancreat Surg. 1998;5(3):303-8. [View Abstract]
  38. Levy MJ, Baron TH, Clayton AC, et al. Prospective evaluation of advanced molecular markers and imaging techniques in patients with indeterminate bile duct strictures. Am J Gastroenterol. May 2008;103(5):1263-73. [View Abstract]
  39. Lipsett PA, Pitt HA, Colombani PM, Boitnott JK, Cameron JL. Choledochal cyst disease. A changing pattern of presentation. Ann Surg. Nov 1994;220(5):644-52. [View Abstract]
  40. Lombard M, Farrant M, Karani J, Westaby D, Williams R. Improving biliary-enteric drainage in primary sclerosing cholangitis: experience with endoscopic methods. Gut. Nov 1991;32(11):1364-8. [View Abstract]
  41. Maier M, Kohler B, Benz C, Korber H, Riemann JF. [Percutaneous transhepatic cholangioscopy (PTCS)--an important supplement in diagnosis and therapy of biliary tract diseases (indications, technique and results)] [German]. Z Gastroenterol. Aug 1995;33(8):435-9. [View Abstract]
  42. McDonald ML, Farnell MB, Nagorney DM, Ilstrup DM, Kutch JM. Benign biliary strictures: repair and outcome with a contemporary approach. Surgery. Oct 1995;118(4):582-90; discussion 590-1. [View Abstract]
  43. Mendler MH, Bouillet P, Sautereau D, et al. Value of MR cholangiography in the diagnosis of obstructive diseases of the biliary tree: a study of 58 cases. Am J Gastroenterol. Dec 1998;93(12):2482-90. [View Abstract]
  44. Moore AV Jr, Illescas FF, Mills SR, et al. Percutaneous dilation of benign biliary strictures. Radiology. Jun 1987;163(3):625-8. [View Abstract]
  45. Morrison MC, Lee MJ, Saini S, Brink JA, Mueller PR. Percutaneous balloon dilatation of benign biliary strictures. Radiol Clin North Am. Nov 1990;28(6):1191-201. [View Abstract]
  46. Nealon WH, Urrutia F. Long-term follow-up after bilioenteric anastomosis for benign bile duct stricture. Ann Surg. Jun 1996;223(6):639-45; discussion 645-8. [View Abstract]
  47. Pereira-Lima JC, Jakobs R, Maier M, et al. Endoscopic biliary stenting for the palliation of pancreatic cancer: results, survival predictive factors, and comparison of 10-French with 11.5-French gauge stents. Am J Gastroenterol. Oct 1996;91(10):2179-84. [View Abstract]
  48. Rosch T, Hofrichter K, Frimberger E, et al. ERCP or EUS for tissue diagnosis of biliary strictures? A prospective comparative study. Gastrointest Endosc. Sep 2004;60(3):390-6. [View Abstract]
  49. Roslyn JJ, Binns GS, Hughes EF. Open cholecystectomy. A contemporary analysis of 42,474 patients. Ann Surg. Aug 1993;218(2):129-37. [View Abstract]
  50. Shah RJ, Langer DA, Antillon MR, Chen YK. Cholangioscopy and cholangioscopic forceps biopsy in patients with indeterminate pancreaticobiliary pathology. Clin Gastroenterol Hepatol. Feb 2006;4(2):219-25. [View Abstract]
  51. Smits ME, Rauws EA, van Gulik TM, et al. Long-term results of endoscopic stenting and surgical drainage for biliary stricture due to chronic pancreatitis. Br J Surg. Jun 1996;83(6):764-8. [View Abstract]
  52. Tenner S, Roston A, Lichtenstein D, et al. Eosinophilic cholangiopathy. Gastrointest Endosc. Mar 1997;45(3):307-9. [View Abstract]
  53. Tocchi A, Mazzoni G, Liotta G, et al. Management of benign biliary strictures: biliary enteric anastomosis vs endoscopic stenting. Arch Surg. Feb 2000;135(2):153-7. [View Abstract]
  54. Vitale GC, George M, McIntyre K. Endoscopic management of benign and malignant biliary strictures. Am J Surg. Jun 1996;171(6):553-7. [View Abstract]
  55. Vitale GC, Larson GM, George M, Tatum C. Management of malignant biliary stricture with self-expanding metallic stent. Surg Endosc. Oct 1996;10(10):970-3. [View Abstract]

Focal intrahepatic benign bile duct stricture after cholecystectomy.

Percutaneous transhepatic cholangiogram with balloon dilation of a postoperative bile duct stricture.

Endoscopic retrograde cholangiopancreatographic cholangiogram demonstrating an isolated mid-hepatic duct stricture as a result of pancreatic cancer.

Focal bile duct stricture as a result of pancreatic cancer in the head of the pancreas.

Endoscopic retrograde cholangiopancreatographic cholangiogram of a solitary benign stricture of the distal bile duct. Resection demonstrated sclerosing cholangitis.

Endoscopic retrograde cholangiopancreatographic cholangiogram demonstrating diffuse stricturing of the intrahepatic ducts that is consistent with primary sclerosing cholangitis.

Periductal onion skin fibrosis seen in primary sclerosing cholangitis.

Periductal lymphocytic and plasma cell infiltrate that is consistent with autoimmune cholangiopathy.

Endoscopic retrograde cholangiopancreatographic cholangiogram demonstrating a long bile duct stricture that represents external compression by gallbladder cancer.

Multiple small bile duct stones seen on magnetic resonance cholangiopancreatography (MRCP).

Endoscopic retrograde cholangiopancreatographic image of a cholangiocarcinoma at the bifurcation of the right and left hepatic ducts (Klatskin tumor).

Endoscopic retrograde cholangiopancreatographic image of a cholangiocarcinoma at the bifurcation of the right and left hepatic ducts (Klatskin tumor).

Endoscopic retrograde cholangiopancreatographic cholangiogram demonstrating a long bile duct stricture that represents external compression by gallbladder cancer.

Endoscopic retrograde cholangiopancreatographic image of a cholangiogram in a patient with cholangiocarcinoma whose condition has been treated with a metal stent.

Endoscopic retrograde cholangiopancreatographic cholangiogram of a solitary benign stricture of the distal bile duct. Resection demonstrated sclerosing cholangitis.

Endoscopic retrograde cholangiopancreatographic cholangiogram demonstrating an isolated mid-hepatic duct stricture as a result of pancreatic cancer.

Endoscopic retrograde cholangiopancreatographic cholangiogram demonstrating diffuse stricturing of the intrahepatic ducts that is consistent with primary sclerosing cholangitis.

Multiple small bile duct stones seen on magnetic resonance cholangiopancreatography (MRCP).

This image is an example of an intraoperative cholangiogram performed during a laparoscopic cholecystectomy.

Percutaneous transhepatic cholangiogram with balloon dilation of a postoperative bile duct stricture.

Periductal onion skin fibrosis seen in primary sclerosing cholangitis.

Periductal lymphocytic and plasma cell infiltrate that is consistent with autoimmune cholangiopathy.

Endoscopic retrograde cholangiopancreatographic image of a cholangiocarcinoma at the bifurcation of the right and left hepatic ducts (Klatskin tumor).

Endoscopic retrograde cholangiopancreatographic image of a cholangiocarcinoma at the bifurcation of the right and left hepatic ducts (Klatskin tumor).

Endoscopic retrograde cholangiopancreatographic cholangiogram demonstrating a long bile duct stricture that represents external compression by gallbladder cancer.

Transhepatic cholangiogram with an external drainage catheter in place.

Endoscopic retrograde cholangiopancreatographic image of a cholangiogram in a patient with cholangiocarcinoma whose condition has been treated with a metal stent.

Endoscopic retrograde cholangiopancreatographic cholangiogram of a solitary benign stricture of the distal bile duct. Resection demonstrated sclerosing cholangitis.

Endoscopic retrograde cholangiopancreatographic cholangiogram demonstrating an isolated mid-hepatic duct stricture as a result of pancreatic cancer.

Endoscopic retrograde cholangiopancreatographic cholangiogram demonstrating diffuse stricturing of the intrahepatic ducts that is consistent with primary sclerosing cholangitis.

Periductal onion skin fibrosis seen in primary sclerosing cholangitis.

Periductal lymphocytic and plasma cell infiltrate that is consistent with autoimmune cholangiopathy.

Focal intrahepatic benign bile duct stricture after cholecystectomy.

Multiple small bile duct stones seen on magnetic resonance cholangiopancreatography (MRCP).

Irregular common bile duct stricture as a result of cholangiocarcinoma.

This image is an example of an intraoperative cholangiogram performed during a laparoscopic cholecystectomy.

Focal bile duct stricture as a result of pancreatic cancer in the head of the pancreas.

Percutaneous transhepatic cholangiogram with balloon dilation of a postoperative bile duct stricture.

Benign distal common bile duct stricture seen during a cholecystostomy injection in an elderly male. The stricture resolved with a 4-week course of oral corticosteroid therapy.