Scarring and narrowing of the bile duct lumen caused by bile duct injury and recurrent cholangitis. It can result from iatrogenic injury, abdominal trauma, bile duct stones, or infection. The affected bile duct undergoes fibrous tissue proliferation, thickening of the duct wall, and narrowing of the lumen due to repeated inflammation and bile salt stimulation. This leads to pathological and clinical manifestations of biliary obstruction and infection.

bubble_chart Clinical Manifestations

History of biliary tract or upper abdominal surgery (trauma), or recurrent cholangitis. (1) Obstructive jaundice within 24 hours post-operation (injury), or a large amount of bile leakage from the drainage site, or asymptomatic in the early post-operation (injury) period, followed by intermittent upper abdominal dull pain, chills, fever, jaundice, and pale stools weeks to years later. (2) Acute episodes may present with Charcot's triad. (3) Chronic cases may exhibit prolonged jaundice, irregular fever patterns, worsening jaundice after fever, biliary cirrhosis, or cholangitis without jaundice. Severe cases progress rapidly, deteriorating quickly, leading to ACST (acute cholangitis of severe type), sepsis, etc.

bubble_chart Diagnosis

1. Medical History and Symptoms

History of biliary tract or upper abdominal surgery (trauma), or recurrent episodes of cholangitis. (1) Within 24 hours post-operation (or injury), obstructive jaundice appears, or a large amount of bile leaks from the drainage site, or early post-operation (injury) without symptoms, followed weeks to years later by intermittent dull upper abdominal pain, chills, fever, jaundice, clay-colored stools, etc. (2) During acute episodes, Charcot's triad may be present. (3) Chronic cases present with prolonged jaundice, irregular fever patterns, worsening jaundice after fever, biliary cirrhosis, or cholangitis without jaundice. Severe cases progress rapidly, deteriorating quickly, leading to ACST, sepsis, etc.

(1) Attack stage: upper abdominal tenderness. (2) Jaundice. (3) Hepatomegaly with tenderness. (4) Possible signs of portal hypertension, etc.

3. Auxiliary Examinations

(1) Elevated white blood cell count and neutrophils; lab tests show obstructive jaundice; severe liver function impairment with inverted albumin-globulin ratio; blood culture may be positive. (2) Retrograde cholangiography, PTC, or ERCP can reveal the location, morphology, and extent of the stricture. Non-visualization of the bile duct does not rule out biliary stricture. Occasionally, intravenous cholangiography may also display the affected bile duct. (3) B-ultrasound may show dilated bile ducts proximal to the stricture and/or sonographic signs of stones.

bubble_chart Treatment Measures

All patients should undergo surgical treatment. For a few with poor general condition, active non-surgical treatment (see bile duct stones and cholangitis) should be prioritized to prepare for surgery.

1. For early fresh bile duct injuries with short strictures, end-to-end anastomosis can be performed, with drainage support for over one year, though long-term outcomes are often unsatisfactory. If end-to-end anastomosis is not feasible, various types of biliary-enteric anastomosis may be performed when conditions permit, with Roux-Y choledochojejunostomy being the most commonly used.

2. For advanced-stage patients with injury-induced strictures or primary bile duct strictures caused by biliary inflammation, biliary-enteric anastomosis is also performed to relieve biliary obstruction (see bile duct stones and cholangitis).

3. For strictures at the hepatic hilum, especially bilateral hepatic duct orifice strictures, the hepatic hilum should be dissected to expose the hepatic duct 2 cm above the stricture, or partial resection of the quadratic lobe may be performed for exposure. The incision should cross both ends of the stricture, and if necessary, reconstruction should be done to enlarge the bile duct lumen. In some cases, the common bile duct (hepatic duct), left and/or right hepatic ducts may need to be incised and anastomosed side-to-side or end-to-side with a Y-shaped jejunal loop. It is essential to remove as many proximal bile duct stones as possible to enhance surgical outcomes.

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5. For primary bile duct strictures with localized and severe liver lesions, partial hepatectomy, often left lateral segmentectomy, may be performed.

6. If multiple lesions are present, accompanied by stones and severe liver parenchymal damage, and simple biliary-enteric anastomosis is insufficient, the aforementioned combined procedures should be employed.

7. In rare cases where definitive repair is impossible, the strictured segment can be supported long-term with a U-tube or dilated using various types of balloon catheters.