Biliary Strictures

A biliary stricture is a narrowing of the bile duct that impedes the normal flow of bile from the liver to the duodenum, leading to cholestasis, jaundice, and — if complicated by infection — cholangitis. Biliary strictures are broadly classified as benign or malignant. Benign strictures most commonly result from iatrogenic bile duct injury during laparoscopic or open cholecystectomy — the most preventable cause, occurring in approximately 0.2–0.4% of cholecystectomies but carrying significant long-term morbidity. Other benign causes include primary sclerosing cholangitis, chronic pancreatitis affecting the intrapancreatic bile duct, post-liver transplant biliary complications, and Mirizzi syndrome. Malignant strictures are caused by cholangiocarcinoma, pancreatic head cancer, gallbladder cancer, or external lymph node compression.

Patients present with progressive jaundice, pale stools, dark urine, pruritus, and fatigue. Recurrent cholangitis with fever and rigors is common with benign strictures, particularly if there is associated biliary sludge or stones. Biochemistry shows elevated direct bilirubin, alkaline phosphatase, and GGT. MRCP is the gold-standard non-invasive investigation for characterising the level, length, and aetiology of a stricture. ERCP allows simultaneous diagnostic sampling (brushings, biopsies) and therapeutic intervention (stenting). Endoscopic ultrasound (EUS) is valuable for assessing masses adjacent to the bile duct.

Management depends on the aetiology and location. Malignant strictures require staging workup and oncological surgery as appropriate. For benign strictures, endoscopic balloon dilation with stenting is effective for short, low strictures and post-transplant anastomotic strictures. However, for longer strictures, post-cholecystectomy injuries involving the biliary confluence, or failed endoscopic therapy, surgical repair with Roux-en-Y hepaticojejunostomy offers the best long-term outcomes with patency rates exceeding 90% at experienced centres. Early expert surgical referral for bile duct injuries is critical — delayed or inadequate repair leads to recurrent stricturing, secondary biliary cirrhosis, and portal hypertension. Our surgeons are experienced in complex biliary reconstruction for all types of stricture.