Biliary Obstruction: Diagnosis and Treatment Procedure

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Biliary obstruction is a relatively common diagnosis in patients with biliary disease, occurs in about 30-50% of the case. It is a form of cholestatic liver disease caused by extrahepatic outflow problem. The majority of patients present with jaundice (yellowing the skin and eyes) and dark urine. Biliary obstruction syndrome includes generalized weakness, loss of appetite, weight loss, feeling tired, and confusion. This triggers initial investigations with blood work and liver ultrasound to try to see whether bile duct dilation is seen.

In typical cases of biliary obstruction, blood work will show elevated levels of bilirubin. Further more advanced testing such as with CT scan or MRI are necessary to locate the obstruction and potential cause of it. It is important to confirm the biliary obstruction diagnosis prior to starting any treatment. Benign condition such as gallstones that have migrated into the main bile duct is the most common cause of biliary obstruction. The treatment of this is with endoscopic removal of the stone(s) via a procedure called ERCP (Endoscopic Retrograde Cholangiopancreatography). This is performed by a gastroenterologist trained in advanced endoscopic procedures. Dr. Sucandy works with several of them within our liver surgery center.

Malignant (cancerous) causes of biliary obstruction include pancreatic cancer, bile duct cancer (cholangiocarcinoma=Klatskin tumor), gallbladder cancer involving the main bile duct, and other cancers compressing the bile duct extrinsically. For the purpose of this discussion, we focus on the bile duct cancer and gallbladder cancer.

Diagnosis of bile duct cancer can be made via MRI showing bile duct obstruction and endoscopic biopsy to try to confirm presence of cancer cells. However, tissue biopsy is difficult to obtain due to solid (difficult to biopsy) nature of this cancer. Biopsy is only positive in 20-30% of patients. Once the suspicion of bile duct cancer is made, bile duct resection is the next step. This requires expertise in liver and biliary surgery since the operation is technically challenging and highly complex. In our liver surgery center, we offer robotic bile duct resection unless contraindications exist. The benefits of minimally invasive surgery are seen in patients with bile duct cancer, similar to those with liver tumors undergoing robotic surgery. Many patients come from out of state for robotic bile duct resection.

If the obstructive biliary disease is caused by intrahepatic cholestatic liver disease, then a multidisciplinary evaluation with a hepatologist maybe necessary. Dr Sucandy works with several experienced hepatologists within our comprehensive liver surgery center to best treat the disease and achieve long-term success.