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Gastroenterology206 papers

Obstruction of biliary tree

Last edited: 4/14/2026

Overview

Obstruction of the biliary tree can result from various etiologies including stones, tumors, inflammation, or strictures, leading to jaundice, pruritus, and potential complications such as cholangitis and pancreatitis. 123456789101112131415161718192021222324252627282930313233343536373839404142434445

Diagnosis

  • Clinical Presentation: Jaundice, abdominal pain, pruritus, and elevated liver enzymes (ALT, AST, ALP, bilirubin). 123456789101112131415161718192021222324252627282930313233343536373839404142434445
  • Imaging Studies:
    • - Ultrasound: Initial imaging to assess biliary dilation and identify common causes. - MRCP/CT Cholangiopancreatography: Detailed visualization of biliary anatomy and obstruction site. 123456789101112131415161718192021222324252627282930313233343536373839404142434445
  • ERCP: Diagnostic and therapeutic, useful for cannulation, sphincterotomy, and stent placement. 123456789101112131415161718192021222324252627282930313233343536373839404142434445

    • Management

  • First-Line Treatments:
    • - ERCP: For both diagnostic evaluation and therapeutic interventions such as sphincterotomy, stone extraction, and stent placement. 123456789101112131415161718192021222324252627282930313233343536373839404142434445 - Percutaneous Transhepatic Cholangiography (PTC): For biliary decompression when ERCP is unsuccessful. 123456789101112131415161718192021222324252627282930313233343536373839404142434445
  • Adjunctive Treatments:
    • - Antibiotic Prophylaxis: Considered to reduce post-ERCP infection risk, especially in

    References

    1 Crinò SF, Aabakken L, Bapaye A, Chan S, Kida M, Law R et al.. World Endoscopy Organization guidelines on endoscopic retrograde cholangiopancreatography biliary cannulation and sphincterotomy techniques. Digestive endoscopy : official journal of the Japan Gastroenterological Endoscopy Society 2025. link 2 Leem G, Sung MJ, Park JH, Kim SJ, Jo JH, Lee HS et al.. Randomized Trial of Prophylactic Antibiotics for Endoscopic Retrograde Cholangiopancreatography in Patients With Biliary Obstruction. The American journal of gastroenterology 2024. link 3 Loganathan P, Mohan B, Baraka A, Gajendran M, Saligram S, Aloysius M et al.. Trainee Involvement and ERCP Complications: A Systematic Review and Meta-Analysis. Digestive diseases and sciences 2024. link 4 Zhang Y, Zhang N, Hu J, Liu C, Li G. Safety and efficacy of a low-dose combination of midazolam, alfentanil, and propofol for deep sedation of elderly patients undergoing ERCP. BMC gastroenterology 2024. link 5 Wang J, Wang S, Wu C, Deng Z. Antibiotic-associated vanishing bile duct syndrome: a real-world retrospective and pharmacovigilance database analysis. Infection 2024. link 6 Fechner C, Reyes Del Castillo T, Roos JE, Zech CJ, Takes M, López Benítez R. 3D Printed Percutaneous Transhepatic Cholangiography and Drainage (PTCD) Simulator for Interventional Radiology. Cardiovascular and interventional radiology 2023. link 7 Pulappadi VP, Srivastava DN, Madhusudhan KS. Diagnosis and management of hemorrhagic complications of percutaneous transhepatic biliary drainage: a primer for residents. The British journal of radiology 2021. link 8 Bundy JJ, Weadock WJ, Chick JFB, Srinivasa RN, Patel N, Johnson E et al.. Three-Dimensional Printing Facilitates Creation of a Biliary Endoscopy Phantom for Interventional Radiology-Operated Endoscopy Training. Current problems in diagnostic radiology 2019. link 9 Schmitz D, Vogl T, Nour-Eldin NA, Radeleff B, Kröger JC, Mahnken AH et al.. Patient radiation dose in percutaneous biliary interventions: recommendations for DRLs on the basis of a multicentre study. European radiology 2019. link 10 García-Cano J, Domper F. Pursuing excellence in ERCP. Revista espanola de enfermedades digestivas 2018. link 11 Hadjiconstanti AC, Messaris GAT, Thomopoulos KC, Solomou AG, Panayiotakis GS. OPTIMISATION OF PATIENT DOSE AND IMAGE QUALITY IN ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY: A PHANTOM-BASED EVALUATION. Radiation protection dosimetry 2017. link 12 Garg MS, Patel P, Blackwood M, Munigala S, Thakkar P, Field J et al.. Ocular Radiation Threshold Projection Based off of Fluoroscopy Time During ERCP. The American journal of gastroenterology 2017. link 13 Cooper J, Desai S, Scaife S, Gonczy C, Mellinger J. Volume, specialty background, practice pattern, and outcomes in endoscopic retrograde cholangiopancreatography: an analysis of the national inpatient sample. Surgical endoscopy 2017. link 14 Boehler ML, Roberts N, Sanfey H, Mellinger J. Do Surgeons and Gastroenterologists Describe Endoscopic Retrograde Cholangiopancreatography Differently? A Qualitative Study. Journal of surgical education 2016. link 15 Dhir V, Itoi T, Fockens P, Perez-Miranda M, Khashab MA, Seo DW et al.. Novel ex vivo model for hands-on teaching of and training in EUS-guided biliary drainage: creation of "Mumbai EUS" stereolithography/3D printing bile duct prototype (with videos). Gastrointestinal endoscopy 2015. link 16 Pan Y, Zhao L, Leung J, Zhang R, Luo H, Wang X et al.. Appropriate time for selective biliary cannulation by trainees during ERCP--a randomized trial. Endoscopy 2015. link 17 Ekkelenkamp VE, Koch AD, Rauws EA, Borsboom GJ, de Man RA, Kuipers EJ. Competence development in ERCP: the learning curve of novice trainees. Endoscopy 2014. link 18 Ray CE, Lorenz JM, Burke CT, Darcy MD, Fidelman N, Greene FL et al.. ACR Appropriateness Criteria radiologic management of benign and malignant biliary obstruction. Journal of the American College of Radiology : JACR 2013. link 19 Liao Z, Li ZS, Leung JW, Zhang X, Zhang ST, Ji M et al.. How safe and successful are live demonstrations of therapeutic ERCP? A large multicenter study. The American journal of gastroenterology 2009. link 20 Villard PF, Vidal FP, Hunt C, Bello F, John NW, Johnson S et al.. A prototype percutaneous transhepatic cholangiography training simulator with real-time breathing motion. International journal of computer assisted radiology and surgery 2009. link 21 Leung JW, Lee W, Wilson R, Lim BS, Leung FW. Comparison of accessory performance using a novel ERCP mechanical simulator. Endoscopy 2008. link 22 Williams EJ, Taylor S, Fairclough P, Hamlyn A, Logan RF, Martin D et al.. Are we meeting the standards set for endoscopy? Results of a large-scale prospective survey of endoscopic retrograde cholangio-pancreatograph practice. Gut 2007. link 23 Laganà D, Carrafiello G, Mangini M, Giorgianni A, Sturniolo G, Dionigi G et al.. An innovative percutaneous technique for the removal and replacement of dysfunctioning plastic biliary endoprostheses (PBE) in the management of malignant billiary occlusions. La Radiologia medica 2007. link 24 Martindale SJ. Anaesthetic considerations during endoscopic retrograde cholangiopancreatography. Anaesthesia and intensive care 2006. link 25 Müller S, Prolla JC, Maguilnik I, Breyer HP. Predictive factors of oxygen desaturation of patients submitted to endoscopic retrograde cholangiopancreatography under conscious sedation. Arquivos de gastroenterologia 2004. link 26 Hatzidakis AA, Charonitakis E, Athanasiou A, Tsetis D, Chlouverakis G, Papamastorakis G et al.. Sedations and analgesia in patients undergoing percutaneous transhepatic biliary drainage. Clinical radiology 2003. link 27 Shah SK, Mutignani M, Costamagna G. Therapeutic biliary endoscopy. Endoscopy 2002. link 28 Neumann M, Mayer G, Ell C, Felzmann T, Reingruber B, Horbach T et al.. The Erlangen Endo-Trainer: life-like simulation for diagnostic and interventional endoscopic retrograde cholangiography. Endoscopy 2000. link 29 Lee DH, Yu JS, Hwang JC, Kim KH. Percutaneous placement of self-expandable metallic biliary stents in malignant extrahepatic strictures: indications of transpapillary and suprapapillary methods. Korean journal of radiology 2000. link 30 Razzaq R, England RE, Martin DF. Technique for providing analgesia during percutaneous biliary interventional procedures. Clinical radiology 2000. link 31 Mannella P, Galeotti R, Causin F, Sala S. Interventional radiology in percutaneous management of bile duct obstruction: biliary drainage through a spontaneous common hepatic duct-duodenal fistula. Clinical imaging 1999. link00088-6) 32 Bogardus ST, Hanan I, Ruchim M, Goldberg MJ. "Mother-baby" biliary endoscopy: the University of Chicago experience. The American journal of gastroenterology 1996. link 33 Picus D. Percutaneous biliary endoscopy. Journal of vascular and interventional radiology : JVIR 1995. link72813-5) 34 Rege RV. Adverse effects of biliary obstruction: implications for treatment of patients with obstructive jaundice. AJR. American journal of roentgenology 1995. link 35 Takehara H, Komi N, Okada A, Masamune K, Asai A. A case of biliary stricture caused by cavernous transformation of the portal vein. Acta paediatrica Japonica : Overseas edition 1993. link 36 Jaschke W, Klose KJ, Strecker EP. A new balloon-expandable tantalum stent (Strecker-Stent) for the biliary system: preliminary experience. Cardiovascular and interventional radiology 1992. link 37 Coons H. Metallic stents for the treatment of biliary obstruction: a report of 100 cases. Cardiovascular and interventional radiology 1992. link 38 Salomonowitz EK, Adam A, Antonucci F, Stuckmann G, Zollikofer CL. Malignant biliary obstruction: treatment with self-expandable stainless steel endoprosthesis. Cardiovascular and interventional radiology 1992. link 39 Brown DM. Bile plug syndrome: successful management with a mucolytic agent. Journal of pediatric surgery 1990. link90086-o) 40 Krongrad A, Kirschenbaum A, Saltzman B. Biliary obstruction complicating extracorporeal shock wave lithotripsy. The Journal of urology 1988. link42407-4) 41 Simmons K. Use of a T tube as an endoprosthesis for internal biliary drainage. Radiology 1985. link 42 Shaw PJ, Spitz L, Watson JG. Extrahepatic biliary obstruction due to stone. Archives of disease in childhood 1984. link 43 Strom PR, Stone HH. A technique for transduodenal sphincteroplasty. Surgery 1982. link 44 Berquist TH, May GR, Johnson CM, Adson MA, Thistle JL. Percutaneous biliary decompression: internal and external drainage in 50 patients. AJR. American journal of roentgenology 1981. link 45 Waye JD. Endoscopic retrograde cholangiopancreatography in the infant. The American journal of gastroenterology 1976. link

    Original source

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      World Endoscopy Organization guidelines on endoscopic retrograde cholangiopancreatography biliary cannulation and sphincterotomy techniques. — Crinò SF, Aabakken L, Bapaye A, Chan S, Kida M, Law R et al. Digestive endoscopy : official journal of the Japan Gastroenterological Endoscopy Society (2025)
    2. [2]
      Randomized Trial of Prophylactic Antibiotics for Endoscopic Retrograde Cholangiopancreatography in Patients With Biliary Obstruction. — Leem G, Sung MJ, Park JH, Kim SJ, Jo JH, Lee HS et al. The American journal of gastroenterology (2024)
    3. [3]
      Trainee Involvement and ERCP Complications: A Systematic Review and Meta-Analysis. — Loganathan P, Mohan B, Baraka A, Gajendran M, Saligram S, Aloysius M et al. Digestive diseases and sciences (2024)
    4. [4]
      Safety and efficacy of a low-dose combination of midazolam, alfentanil, and propofol for deep sedation of elderly patients undergoing ERCP. — Zhang Y, Zhang N, Hu J, Liu C, Li G BMC gastroenterology (2024)
    5. [5]
      Antibiotic-associated vanishing bile duct syndrome: a real-world retrospective and pharmacovigilance database analysis. — Wang J, Wang S, Wu C, Deng Z Infection (2024)
    6. [6]
      3D Printed Percutaneous Transhepatic Cholangiography and Drainage (PTCD) Simulator for Interventional Radiology. — Fechner C, Reyes Del Castillo T, Roos JE, Zech CJ, Takes M, López Benítez R Cardiovascular and interventional radiology (2023)
    7. [7]
      Diagnosis and management of hemorrhagic complications of percutaneous transhepatic biliary drainage: a primer for residents. — Pulappadi VP, Srivastava DN, Madhusudhan KS The British journal of radiology (2021)
    8. [8]
      Three-Dimensional Printing Facilitates Creation of a Biliary Endoscopy Phantom for Interventional Radiology-Operated Endoscopy Training. — Bundy JJ, Weadock WJ, Chick JFB, Srinivasa RN, Patel N, Johnson E et al. Current problems in diagnostic radiology (2019)
    9. [9]
      Patient radiation dose in percutaneous biliary interventions: recommendations for DRLs on the basis of a multicentre study. — Schmitz D, Vogl T, Nour-Eldin NA, Radeleff B, Kröger JC, Mahnken AH et al. European radiology (2019)
    10. [10]
      Pursuing excellence in ERCP. — García-Cano J, Domper F Revista espanola de enfermedades digestivas (2018)
    11. [11]
      OPTIMISATION OF PATIENT DOSE AND IMAGE QUALITY IN ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY: A PHANTOM-BASED EVALUATION. — Hadjiconstanti AC, Messaris GAT, Thomopoulos KC, Solomou AG, Panayiotakis GS Radiation protection dosimetry (2017)
    12. [12]
      Ocular Radiation Threshold Projection Based off of Fluoroscopy Time During ERCP. — Garg MS, Patel P, Blackwood M, Munigala S, Thakkar P, Field J et al. The American journal of gastroenterology (2017)
    13. [13]
      Volume, specialty background, practice pattern, and outcomes in endoscopic retrograde cholangiopancreatography: an analysis of the national inpatient sample. — Cooper J, Desai S, Scaife S, Gonczy C, Mellinger J Surgical endoscopy (2017)
    14. [14]
      Do Surgeons and Gastroenterologists Describe Endoscopic Retrograde Cholangiopancreatography Differently? A Qualitative Study. — Boehler ML, Roberts N, Sanfey H, Mellinger J Journal of surgical education (2016)
    15. [15]
      Novel ex vivo model for hands-on teaching of and training in EUS-guided biliary drainage: creation of "Mumbai EUS" stereolithography/3D printing bile duct prototype (with videos). — Dhir V, Itoi T, Fockens P, Perez-Miranda M, Khashab MA, Seo DW et al. Gastrointestinal endoscopy (2015)
    16. [16]
      Appropriate time for selective biliary cannulation by trainees during ERCP--a randomized trial. — Pan Y, Zhao L, Leung J, Zhang R, Luo H, Wang X et al. Endoscopy (2015)
    17. [17]
      Competence development in ERCP: the learning curve of novice trainees. — Ekkelenkamp VE, Koch AD, Rauws EA, Borsboom GJ, de Man RA, Kuipers EJ Endoscopy (2014)
    18. [18]
      ACR Appropriateness Criteria radiologic management of benign and malignant biliary obstruction. — Ray CE, Lorenz JM, Burke CT, Darcy MD, Fidelman N, Greene FL et al. Journal of the American College of Radiology : JACR (2013)
    19. [19]
      How safe and successful are live demonstrations of therapeutic ERCP? A large multicenter study. — Liao Z, Li ZS, Leung JW, Zhang X, Zhang ST, Ji M et al. The American journal of gastroenterology (2009)
    20. [20]
      A prototype percutaneous transhepatic cholangiography training simulator with real-time breathing motion. — Villard PF, Vidal FP, Hunt C, Bello F, John NW, Johnson S et al. International journal of computer assisted radiology and surgery (2009)
    21. [21]
      Comparison of accessory performance using a novel ERCP mechanical simulator. — Leung JW, Lee W, Wilson R, Lim BS, Leung FW Endoscopy (2008)
    22. [22]
      Are we meeting the standards set for endoscopy? Results of a large-scale prospective survey of endoscopic retrograde cholangio-pancreatograph practice. — Williams EJ, Taylor S, Fairclough P, Hamlyn A, Logan RF, Martin D et al. Gut (2007)
    23. [23]
      An innovative percutaneous technique for the removal and replacement of dysfunctioning plastic biliary endoprostheses (PBE) in the management of malignant billiary occlusions. — Laganà D, Carrafiello G, Mangini M, Giorgianni A, Sturniolo G, Dionigi G et al. La Radiologia medica (2007)
    24. [24]
      Anaesthetic considerations during endoscopic retrograde cholangiopancreatography. — Martindale SJ Anaesthesia and intensive care (2006)
    25. [25]
      Predictive factors of oxygen desaturation of patients submitted to endoscopic retrograde cholangiopancreatography under conscious sedation. — Müller S, Prolla JC, Maguilnik I, Breyer HP Arquivos de gastroenterologia (2004)
    26. [26]
      Sedations and analgesia in patients undergoing percutaneous transhepatic biliary drainage. — Hatzidakis AA, Charonitakis E, Athanasiou A, Tsetis D, Chlouverakis G, Papamastorakis G et al. Clinical radiology (2003)
    27. [27]
      Therapeutic biliary endoscopy. — Shah SK, Mutignani M, Costamagna G Endoscopy (2002)
    28. [28]
      The Erlangen Endo-Trainer: life-like simulation for diagnostic and interventional endoscopic retrograde cholangiography. — Neumann M, Mayer G, Ell C, Felzmann T, Reingruber B, Horbach T et al. Endoscopy (2000)
    29. [29]
      Percutaneous placement of self-expandable metallic biliary stents in malignant extrahepatic strictures: indications of transpapillary and suprapapillary methods. — Lee DH, Yu JS, Hwang JC, Kim KH Korean journal of radiology (2000)
    30. [30]
      Technique for providing analgesia during percutaneous biliary interventional procedures. — Razzaq R, England RE, Martin DF Clinical radiology (2000)
    31. [31]
      Interventional radiology in percutaneous management of bile duct obstruction: biliary drainage through a spontaneous common hepatic duct-duodenal fistula. — Mannella P, Galeotti R, Causin F, Sala S Clinical imaging (1999)
    32. [32]
      "Mother-baby" biliary endoscopy: the University of Chicago experience. — Bogardus ST, Hanan I, Ruchim M, Goldberg MJ The American journal of gastroenterology (1996)
    33. [33]
      Percutaneous biliary endoscopy. — Picus D Journal of vascular and interventional radiology : JVIR (1995)
    34. [34]
      Adverse effects of biliary obstruction: implications for treatment of patients with obstructive jaundice. — Rege RV AJR. American journal of roentgenology (1995)
    35. [35]
      A case of biliary stricture caused by cavernous transformation of the portal vein. — Takehara H, Komi N, Okada A, Masamune K, Asai A Acta paediatrica Japonica : Overseas edition (1993)
    36. [36]
      A new balloon-expandable tantalum stent (Strecker-Stent) for the biliary system: preliminary experience. — Jaschke W, Klose KJ, Strecker EP Cardiovascular and interventional radiology (1992)
    37. [37]
      Metallic stents for the treatment of biliary obstruction: a report of 100 cases. — Coons H Cardiovascular and interventional radiology (1992)
    38. [38]
      Malignant biliary obstruction: treatment with self-expandable stainless steel endoprosthesis. — Salomonowitz EK, Adam A, Antonucci F, Stuckmann G, Zollikofer CL Cardiovascular and interventional radiology (1992)
    39. [39]
      Bile plug syndrome: successful management with a mucolytic agent. — Brown DM Journal of pediatric surgery (1990)
    40. [40]
      Biliary obstruction complicating extracorporeal shock wave lithotripsy. — Krongrad A, Kirschenbaum A, Saltzman B The Journal of urology (1988)
    41. [41]
      Use of a T tube as an endoprosthesis for internal biliary drainage. — Simmons K Radiology (1985)
    42. [42]
      Extrahepatic biliary obstruction due to stone. — Shaw PJ, Spitz L, Watson JG Archives of disease in childhood (1984)
    43. [43]
      A technique for transduodenal sphincteroplasty. — Strom PR, Stone HH Surgery (1982)
    44. [44]
      Percutaneous biliary decompression: internal and external drainage in 50 patients. — Berquist TH, May GR, Johnson CM, Adson MA, Thistle JL AJR. American journal of roentgenology (1981)
    45. [45]
      Endoscopic retrograde cholangiopancreatography in the infant. — Waye JD The American journal of gastroenterology (1976)
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