Biliary tract obstruction in chronic pancreatitis

Abstract

Bile duct strictures are a common complication in patients with advanced chronic pancreatitis and have a variable clinical presentation ranging from an incidental finding to overt jaundice and cholangitis. The diagnosis is mostly made during investigations for abdominal pain but jaundice may be the initial clinical presentation. The jaundice is typically transient but may be recurrent with a small risk of secondary biliary cirrhosis in longstanding cases. The management of a bile duct stricture is conservative in patients in whom it is an incidental finding as the risk of secondary biliary cirrhosis is negligible. Initial conservative treatment is advised in patients who present with jaundice as most will resolve once the acute on chronic attack has subsided. A surgical biliary drainage is indicated when there is persistent jaundice for more than one month or if complicated by secondary gallstones or cholangitis. The biliary drainage procedure of choice is a choledocho-jejunostomy which may be combined with a pancreaticojejunostomy in patients who have associated pain. Since many patients with chronic pancreatitis have an inflammatory mass in the head of the pancreas, a Frey procedure is indicated but a resection should be performed when there is concern about a malignancy. Temporary endoscopic stenting is reserved for cholangitis while an expandable metal stent may be indicated in patients with severe co-morbid disease.

Figure 1.

CT scan showing chronic calcific pancreatitis. 1b. CT scan showing pancreatic calcification and common bile duct dilatation (arrow).

Figure 2.

Cholangiographic appearance of bile duct strictures (as identified by Caroli & Nora) . Type I: Long retropancreatic stenosis. Type II: Dilatation of the main bile duct, stricture of the sphincter of oddi. Type III: Hourglass stricture. Type IV: Symptomatic of either a cyst (a), or a cancer (b and c). Type V: Cancer of the pancreas.

Figure 3.

ERC demonstrating a smooth tapering biliary stricture in a patient with chronic calcific pancreatitis. 3b. MRCP showing dilated extrahepatic bile duct with smooth tapering stricture.

Figure 4.

Management algorithm: biliary obstruction in chronic pancreatitis.