The Spectrum and Natural History of Common Bile Duct Stenosis in Chronic Alcohol-Induced Pancreatitis

Abstract

Sixty patients with chronic alcohol-induced pancreatitis with endoscopic retrograde cholangiopancreatography evidence of common bile duct stenosis were studied to determine the clinical spectrum and natural history of this complication, as well as the indications for biliary bypass. In 17% of patients, common bile duct stenosis (CBDS) was an incidental finding at ERCP, while in the remaining cases pain and jaundice were the predominant symptoms in 35% and 48%, respectively. Biliary drainage was performed in 38% of patients for persistent or recurrent jaundice, cholangitis, and while undergoing pancreatic duct or cyst drainage procedures for pain. The benign nature of CBDS in chronic alcohol-induced pancreatitis (CAIP) in patients without persistent jaundice is emphasized. In particular, no histologically proved cases of secondary biliary cirrhosis were noted. The majority of patients with CBDS due to CAIP may be safely managed without biliary bypass but require close follow-up.

Italian consensus guidelines for chronic pancreatitis

“…After a mean of 38 months follow-up, 84% of patients remained pain-free [198]. Asymptomatic common bile duct dilation in patients with normal liver function tests may be detected by imaging techniques (MRCP, CT) in patients with chronic pancreatitis [201][202][203][204]. There are no predictive factors available to stratify the risk of developing cholestasis and secondary biliary cirrhosis, and to determine which patients could benefit from an endoscopic therapy.…”

“…There are no predictive factors available to stratify the risk of developing cholestasis and secondary biliary cirrhosis, and to determine which patients could benefit from an endoscopic therapy. Conservative management is highly recommended in these patients [202,204]. Plastic stent placement is effective for short-term resolution of symptomatic biliary strictures.…”

Benign biliary strictures

“…Most patients with CBD stenosis associated with chronic pancreatitis can be managed without biliary bypass (Kalvaria et al, 1989;Smits et al, 1996). In a series of 240 patients with chronic pancreatitis, 39 of whom came to operation, nine had symptomatic biliary obstruction, and 13 were subjected to some form of biliary-enteric anastomosis, either alone or associated with excisional surgery for pancreatic disease.…”

Biliary tract obstruction in chronic pancreatitis

“…The wide variation in the reported incidence, which ranges from 3% to 46%1–8 (Table I), occurs because not all patients with biliary obstruction in CP present with jaundice. The jaundice may frequently be transient [9], and in an appreciable number of patients the bile duct stricture is discovered incidentally 10–14.…”

“…This “incidental” presentation occurs in up to 17% of patients [13]. Although pain is the predominant clinical feature in most patients 2, 3, 8, 13, 26, it is doubtful that a CBDS per se is a major contributing factor. Jaundice is present in 30% [10] to 50% [13] of patients, and may be transient, recurrent, or persistent [26].…”