Back to Chronic Cholestasis

Introduction

Biliary stricture may occur as a result of chronic inflammatory diseases such as cholangitis or pancreatitis. It may also be secondary to bile duct injury from previous surgery such as cholecystectomy (secondary sclerosing cholangitis). In addition, since the hepatic artery supplies the bile ducts, arterial stenosis or arterio-venous shunting can also give rise to bile duct strictures. Chronic bile duct strictures with the resulting chronic cholestasis can lead to cirrhosis (secondary biliary cirrhosis) in a relatively short period of time. Therefore, symptoms and signs of cirrhosis should be investigated in these patients.

History

Jaundice and abdominal pain may or may be present, but are not universal. Long-standing cholestasis may lead to deficiency of fat-soluble vitamins (A, D, E, K), and the associated signs and symptoms (e.g. night blindness, osteoporosis, bruisability). Weight loss and pruritus are also common. A long-standing alcohol history should raise suspicion for chronic pancreatitis. A history of biliary colic may suggest secondary sclerosing cholangitis. In patients with ulcerative colitis (UC), primary sclerosing cholangitis (PSC) should be ruled out because of the strong association between the two entities.

Physical examination

There are no specific findings. Scleral icterus may be present. Excoriation marks may be evident in case of pruritus. Stigmata of chronic liver disease may be present, such as palmar erythema, vascular spiders and muscle hypotrophy, particularly if cirrhosis is present.

Investigation

EUS, MRCP, ERCP, cytology of bile duct brushing, doppler ultrasound (if hepatic artery stenosis is suspected).