Biliary obstruction refers to blockage of the bile duct system preventing bile from flowing from the liver into the intestinal tract. Bile is synthesized in the liver and transported via the bile ducts into the duodenum to assist with the metabolism of fats. Bile is a substance produced continuously by the hepatocytes consisting of bile salts, bilirubin, fats, water, and inorganic salts. Bile formed in the liver flows through the right and left hepatic ducts into the common hepatic duct. Nearly 50% of the bile flows into the cystic duct and is then stored in the gallbladder with the rest of the bile flowing through the common bile duct and converging and flowing through the main pancreatic duct in the head of the pancreas to empty into the duodenum through the sphincter of Oddi. Biliary obstruction can occur anywhere along this path and lead to serious complications such as hepatic dysfunction, renal failure, cardiovascular impairment, nutritional deficiencies, bleeding problems, and infection.
Bile obstruction is common and affects a large portion of the population around the world with significant morbidity and mortality. The most common etiology of biliary obstruction is from gallstones which commonly manifest by dilatation of the common bile duct and jaundice.
The socioeconomic and demographic diversity of biliary obstruction can be evidenced in the most common cause - in developed countries of the western world, cholelithiasis secondary to cholesterol stones in the most common cause, whereas brown pigment stones in the bile ducts are most common in Asia
Oriental cholangiohepatitis which is characterized by recurrent bacterial cholangitis, dilatation, and stricturing of the biliary tree, the presence of calculi within the intrahepatic bile ducts, and an increased risk for cholangiocarcinoma is common in Asia but rare in the west
Gallbladder malignancy is more common in Central and South America, Central and Eastern Europe, the northern Indian subcontinent, and East Asia
Women are at greater risk of developing gallstones than men; likely secondary to the effect of estrogen increasing hepatic uptake of cholesterol which increases bile production
Catabolism of hemoglobin is a normal function that releases heme molecules which then converts to biliverdin, a precursor to bilirubin. Biliverdin then transforms into unconjugated bilirubin within the reticuloendothelial system. Being that unconjugated bilirubin is lipid soluble, the renal system does not eliminate it. Unconjugated bilirubin is bound in serum to albumin or exists as free unbound bilirubin. Unbound bilirubin is taken up by hepatocytes and converted to conjugated bilirubin which is water soluble. Conjugated bilirubin becomes part of the bile which is secreted from the hepatocytes in the liver.
Bile formed in the liver flows through the right and left hepatic ducts into the common hepatic duct. Fifty percent of the bile flows into the cystic duct and is then stored in the gallbladder with the rest of the bile flowing through the common bile duct and converging and flowing through the main pancreatic duct in the head of the pancreas to empty into the duodenum through the sphincter of Oddi.
Biliary obstruction refers to blockage of the bile duct system preventing bile release. Biliary obstruction can occur anywhere along the path from the liver to the intestinal tract. Biliary obstruction is common and affects a large portion of the population around the world with significant morbidity and mortality. Gallstones are the most prevalent cause of biliary obstruction; they commonly manifest by dilatation of the common bile duct and jaundice.
Jaundice, a physical exam finding of yellowish discoloration of the skin, conjunctiva, and/or mucous membranes is a consequence of obstruction leading to bile stasis and buildup of conjugated bilirubin in the blood.
Normal total serum bilirubin values are 0.2-1.2 mg/dL. Jaundice is evident clinically at the level of 3 mg/dl.
Normal urine contains no bilirubin; however, in patients with obstructive jaundice conjugated bilirubin is excreted in urine giving it a dark color. Urinary bilirubin is detectable at a lower level of bilirubin than that needed to cause clinical jaundice.
The inability of bilirubin to reach the intestinal tract gives pale color to stools.
Pruritus is common in biliary obstruction patients, but the cause of this is unknown. Deposition of bile acid into the skin is one postulation that could account for these symptoms. Percutaneous biliary drainage was found to decrease pruritis symptoms.
Cytology brushing and tissue biopsy to make a tissue diagnosis may be necessary for the workup for an unknown mass obstructing the biliary tract. This procedure can be performed at the time of an ERCP or by percutaneous or endoscopic ultrasound-directed biopsy.
History and Physical
Yellowing of skin and eyes
Right upper quadrant abdominal pain
Intractable nausea and vomiting
Age and associated comorbidities
Pain including site and characteristics
Duration of symptoms
Pattern of jaundice
History of malignancy or jaundice
Known history of gallstone disease
History of gastrointestinal bleeding
History of hepatitis
History of biliary intervention
History of alcohol intake, drug use, and medications
History of blood transfusions
Family history of jaundice or malignancy
Weight and BMI
Signs of jaundice; yellowing of skin and icterus
Palpate for hepatomegaly and splenomegaly
Examine for ascites
Palpate for a palpable mass
Look for signs of cirrhosis
Examine for palpable gallbladder (Courvoisier sign)
Digital Rectal Examination
Rectal shelf for rectal metastasis
Left supraclavicular lymph node, other neck lymph nodes
Prognosis of biliary obstruction is highly dependent on the etiology. If left untreated, it can lead to life-threatening infection. If obstruction is persistent and chronic, it is usually due to a chronic liver pathology which commonly has a poor prognosis. Most acute causes can be successfully managed with medical, surgical, and/or endoscopic treatment with full recovery. Obstruction caused by chronic liver disease and carcinoma usually has a less favorable prognosis.
One of the most feared complications of biliary obstruction is cholangitis which is an ascending infection of the biliary tree accompanying an obstruction
Charcot’s triad (right upper quadrant pain, fever, and jaundice)
Reynold’s pentad (Charcot's triad with mental status change and hemodynamic shock)
Elevated white blood cell count
Abnormal liver testing with elevated alkaline phosphatase and gamma-glutamyl transpeptidase
Antibiotics with activity against enteric streptococci, coliforms, and anaerobes
Single-agent: ertapenem or piperacillin-tazobactam
Combination: ceftriaxone, ciprofloxacin, or levofloxacin with metronidazole
Single-agent: imipenem-cilastatin, meropenem, or piperacillin-tazobactam
Combination: cefepime or ceftazidime with metronidazole
ERCP (endoscopic retrograde cholangiopancreatography); Endoscopic removal of biliary stones with drainage of bile, often with sphincterotomy
PTC (percutaneous transhepatic cholangiography); Insertion of a needle into biliary tract percutaneously for drainage, removal of stones, and possible placement of the biliary stent
Surgical Drainage; Open or laparoscopic surgical intervention with biliary decompression, removal of the obstruction, and cholecystectomy if warranted and the patient is stable
Deterrence and Patient Education
Blockage within the biliary tract or the route bile uses to leave the liver and help metabolize fat
Most Common Cause
Gallbladder stones that obstruct the biliary tract
Right upper quadrant abdominal pain
Pain in the back under the shoulder blade
Nausea and vomiting
Jaundice (yellowing of the skin)
Laboratory evaluation and imaging
Ultrasound of the abdomen
Further testing will be chosen appropriately depending on the results of initial testing
Treatment for biliary obstruction depends on the cause but likely will be either surgical or non-surgical
Surgical may include cholecystectomy to remove the gallbladder if the cause is gallstones along with ERCP with sphincterotomy to remove any gallstones from the biliary tract causing obstruction
Non-Surgical may include stabilization and pain control along with medications to help dissolve any gallstones causing obstruction
Prevention of recurrence
Maintain a healthy body weight with proper nutrition and exercise
Enhancing Healthcare Team Outcomes
Biliary obstruction is a term encompassing many separate conditions that result in a typical clinical finding of elevated bilirubin. Patients may first present to their primary care physicians, nurse practitioner or an emergency room for treatment. The prompt initial diagnosis helps drive therapy and improve outcomes in most patients. Special attention is necessary to rule out ascending infection when patients present with findings of biliary obstruction due to the poor prognosis of ascending cholangitis and cancer. Initial laboratory and radiographic assessment will determine the proper specialty needed to treat the obstruction whether that be general surgery, gastroenterology, oncology or interventional radiology.
Naumowicz E,Białecki J,Kołomecki K, Results of treatment of patients with gallstone disease and ductal calculi by single-stage laparoscopic cholecystectomy and bile duct exploration. Wideochirurgia i inne techniki maloinwazyjne = Videosurgery and other miniinvasive techniques. 2014 Jun [PubMed PMID: 25097684]