Diagnosis and Treatment of Distal Biliary Obstruction

A.A. Stukalo


Introduction. Improving early diagnosis and treatment tactics and techniques of endoscopic interventions in patients with diseases that cause distal biliary obstruction, is one of the most pressing problems in biliopancreatic surgery, and the results require further study.
Purpose of the study. To improve the results of diagnosis and treatment of patients with distal biliary obstruction.
Object and methods. The object of study was to analyze the diagnostic methods and treatment outcomes in 1251 patients with distal biliary obstruction. The median age was 69.3 ± 8.1 years. Women — 1671 (64 %), men — 940 (36 %). All patients underwent ultrasound examinations of biliopancreatic zone, duodenoscopy, if necessary, a computer tomography. Biliary hypertension eliminated by transpapillary endoscopic interventions, and/or implementation of the various options holecysto-/holangiostomy.
Results and discussion. Five groups of patients are identified. The first group — 383 (30.6 %) patients with malignant tumors of terminal part of the common bile duct (TPCBD). The second group was 137 (11 %) patients with benign tumors of the major duodenal papilla (MDP). The third group was 423 (33.8 %) patients with parapapillary diverticulum. The fourth group consisted of 169 (13.5 %) patients with penetrations TPCBD or MDP stones. Fifth group — 139 (11.1 %) patients with inflammatory and cicatricial stenosis.
Manifestations of obstructive jaundice with hyperbilirubinemia from 22 to 467 mcmol/l were detected in 972 (77.7 %) patients.
Patients with neoplastic processes were characterized by painless onset, long, for two — eight weeks, the presence of small signs of cancer, periodic chills, fever, relapsing jaundice. Significant weight loss in history indicated a high probability of malignancy process.
For patients with penetrations TPCBD stones were typical acute pain onset, severe clinical picture of biliary colic and acute pancreatitis.
In contrast to benign causes in patients with malignant lesions hyperbilirubinemia level was more significant, exceeded 200 mcmol/l.
Typical ultrasound signs of distal CBD obstruction — CBD dilatation > 8 mm, and/or the main pancreatic duct > 2 mm. The presence of endoscopic signs depends on the location and extent of obstructive process in the papillary or intramural segments.
The preferred methods of elimination of obstruction are transpapillary interventions. In patients with stenosing mouth MDP and the inability of cannulation used atypical ways papillotomy (precut or needle papillotomy). When cut a length of 8 mm and an inability to cannulation of the bile duct further endoscopic recognized risky activities, and conducted a landmark intervention in 3–4 days after drug prevention possible pancreatitis.
The greatest difficulties in technical terms were in patients with a stone blocking the pancreatic part of CBD. In these patients, there is no extension of papillary and intramural segments TPCBD; it is difficult to conduct retrograde a basket proximal locking stone, intervention occurs more traumatic. Numerous attempts to extract such a stone may cause necrotizing pancreatitis and/or retroperitoneal perforation.
Conclusions. Distal biliary obstruction in more than 40 % of patients causes neoplastic processes. In diagnostics, the leading role belongs to ultrasound and endoscopic techniques with specific characteristics.
Endosurgical techniques are effective in more than 88 % of patients with benign obstruction and in 53 % of patients with a tumor stenosis.


transpapillary interventions; stenosis of the major duodenal papilla; tumor; parapapillary diverticulum


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DOI: https://doi.org/10.22141/1997-2938.1.24.2014.82866


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