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.

Italian consensus guidelines for chronic pancreatitis

“…pain), as well as by the suspicion of an underlying malignancy. A conservative approach has been advocated in minimally symptomatic patients with transient jaundice and in the absence of substantial alterations of liver function [255]. Recurrent jaundice or clinical presentation with cholangitis are indications for endoscopic stent placement, which has been shown to be a safe and effective procedure, with a complication rate ranging from 4% to 7% [256,257].…”

Frey procedure combined with biliary diversion in chronic pancreatitis

“…However, an inflammatory pancreatic head mass could also affect adjacent organs. Common bile duct (CBD) stricture appears in 3 to 46% of patients and could lead to chronic cholestasis, cholangitis, and eventually to secondary biliary cirrhosis 2 . In addition to pancreatic head cancer, painful inflammatory pancreatic head mass has long been considered to be a classic indication for pancreaticoduodenectomy (PD).…”

Etiological spectrum of recurrent jaundice in adults: A retrospective observational study from a tertiary care center

“…Acute or chronic relapsing pancreatitis can cause a recurrence of cholestatic jaundice. [13] Two female and one male case of relapsing pancreatitis in our study were due to cholelithiasis and alcohol consumption, respectively. Autoimmune pancreatitis (AIP) and IgG4 related disease can cause recurrent jaundice during its natural course or steroid tapering or withdrawal.…”