A biliary stricture is similar to a traffic jam in your liver's drainage system. It involves narrowing that can obstruct the flow of bile, a substance produced by your liver to aid in food digestion. Sometimes, you might not notice anything wrong at first, even though there could be underlying issues with your liver.

The reason most doctors worry about these narrowings is that they can often be caused by cancer, either in the liver or starting from other places in your body. When a doctor identifies that you have a biliary stricture, they focus on figuring out two main things: whether cancer is causing it and how to unblock the flow of bile into your small intestine.

First, they'll want to make sure whether the stricture is caused by cancer or not. After that, they'll plan how to remove the blockage and restore the normal bile flow. Depending on the location of this traffic jam or narrowing, whether it's outside the liver, close to the liver, or inside the liver, the doctor will employ different methods.

These guidelines act as a GPS for doctors, providing the best and most reliable directions on treating patients with specific types of blockages in the bile ducts located outside and close to the liver. They primarily focus on helping doctors accurately identify these blockages and unblock the bile flow.

While some of the ways to find and fix blockages mentioned here might also work for blockages inside the liver, this document doesn't focus on those. Another guideline by the American College of Gastroenterology (ACG) talks about how to handle blockages related to a condition called primary sclerosing cholangitis (PSC). Lastly, this document won't go into the details of surgery or cancer care for these blockages, except for procedures done through an endoscope.

   

The guidelines provide the following recommendations:

 

1. If your bile duct (the tube that carries bile from the liver to the intestine) is narrowing, it is often associated with cancer, but not always. There are situations where this can occur due to non-cancerous causes.
2. If your bile duct outside the liver is narrow and there might be a lump in your pancreas, doctors prefer to use a procedure called EUS* with fine-needle sampling to check for cancer. This method provides a better understanding of whether the narrowing is caused by cancer. 
   *EUS (Endoscopic Ultrasound) is a procedure that uses sound waves to create detailed images of the digestive tract and nearby organs. It can help to identify the cause of problems like narrowed bile ducts.
3. If the narrowed bile duct is outside your liver, you're not experiencing major symptoms, and there's a possible lump in your pancreas, doctors suggest performing two procedures – EUS and ERCP – together, rather than just the ERCP. These two tests can determine the cause of the problem and clear the blockage in the bile duct simultaneously.
   ** ERCP (Endoscopic Retrograde Cholangiopancreatography) is a procedure that combines endoscopy and X-rays to examine the ducts (tubes) that drain the liver, gallbladder, and pancreas. It is used to diagnose and treat conditions such as blocked bile ducts.
4. If your bile duct is narrowed due to a possible lump in your pancreas, doctors recommend using EUS with a method called FNB (fine-needle biopsy) or FNA (fine-needle aspiration) with quick on-site evaluation (ROSE) to collect tissue samples. This method is preferable to using FNA without ROSE, as it provides a quicker and more accurate evaluation of the tissue, helping determine the cause of the bile duct narrowing.
5. If your bile ducts near the liver are narrowed due to a possible type of cancer called cholangiocarcinoma, doctors should avoid certain biopsy procedures to collect tissue samples from the main tumor. Instead, they will use a different method called intraductal sampling. The other biopsy methods should be reserved for collecting samples from swollen lymph nodes related to the main tumor.
6. If you have a narrowing in the bile ducts near the liver that could be due to cancer, doctors recommend using a combination of different methods to collect tissue samples during ERCP. This approach increases the likelihood of accurately determining whether the narrowing is caused by cancer.
7. If your bile duct outside the liver is narrowed due to a non-cancerous condition, doctors suggest using a special kind of stent called fcSEMS (fully covered self-expandable metal stent) instead of multiple plastic stents. This stent can remain in place for a longer duration, reducing the need for frequent replacements.
8. If you have a non-cancerous narrowing in the bile duct outside the liver, the treatment duration should be 12 months when using multiple plastic stents and at least 6 months when using fcSEMSs. However, using fcSEMSs for 12 months may offer even more benefits. If the aim is to use fcSEMSs for 12 months, the stent should be replaced at the 6-month mark to prevent complications.
9. If you have a non-cancerous narrowing in the bile duct, and your gallbladder is still in place, doctors may choose to use multiple plastic stents instead of fcSEMSs if the metallic stent can't avoid the duct connecting the gallbladder to the bile duct. This is because using fcSEMSs in this situation might increase the risk of inflammation in the gallbladder.
10. When you have a narrowed bile duct outside the liver caused by a type of cancer that can be surgically removed, doctors generally don't recommend draining the bile before the surgery unless you experience certain issues, such as severe itching, very high levels of bilirubin in the blood, or a long delay before the surgery.
11. When you have a narrowed bile duct outside the liver due to cancer that can't be completely removed, or it's borderline removable, the doctors recommend using a self-expandable metallic stent (SEMS) to help keep the bile duct open.
12. Before placing a non-removable metallic stent to treat a narrowed bile duct, it's important to confirm the cause as cancer, as this type of stent cannot be removed once inserted.
13. If you have a narrowed bile duct outside the liver due to cancer and might be eligible for a surgical procedure called pancreaticoduodenectomy (also known as the Whipple procedure), doctors may place a non-removable metallic stent. The placement should allow enough space for the surgeon to safely cut and reconnect the bile duct during the procedure.
14. For patients with cancerous narrowing in the bile duct outside the liver that can't be fully removed or is borderline removable, there isn't enough evidence to definitively recommend using either a non-covered metallic stent or a fully covered metallic stent to treat the blockage.
15. If your bile ducts near the liver are blocked because of cancer, and you're experiencing yellowing of the skin and eyes but no other major symptoms, and you have chosen not to have additional treatments, you may not necessarily need a procedure to drain the blockage.
16. For patients with a narrowed bile duct near the liver suspected of being caused by cancer, there isn't enough evidence to definitively recommend using either ERCP or PTBD (a procedure that drains bile via an access through the skin) to treat the condition.
17. ERCP, which is used to diagnose and treat narrowed bile ducts near the liver, should be performed by experienced doctors who have received proper training.
18. When treating a narrowed bile duct in the area near the liver, the focus should be on draining more than half of the healthy liver.
19. For patients with a narrowed bile duct near the liver due to cancer in the region where the liver and bile ducts meet, there isn't enough evidence to recommend using either plastic stents or non-covered metallic stents for treating the condition.
20. If a metallic stent is to be used for draining a narrowed bile duct caused by cancer in the region where the liver and bile ducts meet, it's important that the effectiveness of plastic stents has been proven first.
21. If you have a condition where the bile duct near your liver is narrower than it should be due to a specific type of cancer known as cholangiocarcinoma, and either surgery to remove the cancer or a liver transplant is not an option for you, a combination of treatments is suggested. One part of the treatment involves placing a plastic tube, called a stent, to help with the bile duct blockage. Additionally, adjuvant endobiliary ablation is recommended. This process involves destroying harmful cells either by using a special kind of light treatment called photodynamic therapy (PDT) or by using heat through radiofrequency ablation (RFA). Using these treatments together is more effective than solely inserting the plastic stent to manage the blockage caused by the cancer.
22. If your bile duct is narrower than it should be, and you require a procedure known as ERCP, but it cannot be done successfully or at all, an alternative procedure called EUS-guided biliary access/drainage is suggested instead of PTBD. This recommendation is based on the fact that EUS-guided procedures generally result in fewer complications and side effects. However, it is crucial that this procedure be performed by a doctor who is highly experienced and skilled in conducting these specific types of procedures.

This article aims to help you understand medical practices for dealing with narrowings in the bile ducts outside and near the liver (referred to as extrahepatic and perihilar strictures). The recommendations focus on how doctors diagnose this condition and manage fluid drainage from the affected areas. These tips are endorsed by medical experts from prestigious institutions such as UCLA, The Medical University of South Carolina, The University of Texas Southwestern, The Penn State Hershey Medical Center, and Mayo Clinic Florida.
 

By Tossapol Kerdsirichairat, MD
Clinical Associate Professor of Medicine
Advanced/Bariatric Endoscopy, Digestive Disease Center
Bumrungrad International Hospital