Biliary obstruction refers to blockage of the bile duct system preventing bile from flowing from the liver into the intestinal tract. Bile is synthesized in the liver and transported via the bile ducts into the duodenum to assist with the metabolism of fats. Bile is a substance produced continuously by the hepatocytes consisting of bile salts, bilirubin, fats, water, and inorganic salts. Bile formed in the liver flows through the right and left hepatic ducts into the common hepatic duct. Nearly 50% of the bile flows into the cystic duct and is then stored in the gallbladder with the rest of the bile flowing through the common bile duct and converging and flowing through the main pancreatic duct in the head of the pancreas to empty into the duodenum through the sphincter of Oddi. Biliary obstruction can occur anywhere along this path and lead to serious complications such as hepatic dysfunction, renal failure, cardiovascular impairment, nutritional deficiencies, bleeding problems, and infection.
Biliary obstruction is generally referred to blockage of extrahepatic biliary system. Disruption in bile flow due to hepatic or intrahepatic biliary system is genrally referred as cholestasis. All these can present as elevated bilirubin levels and Jaundice.
Bile obstruction is common and affects a large portion of the population around the world with significant morbidity and mortality. The most common etiology of biliary obstruction is from Choledhocholithiasis or gallstone causing extrahepatic bile duct blockage. The most serious manifestation of this is infection of bile ducts or cholangitis which can be fatal if not treated promptly. 
Biliary obstruction can divided into intrahepatic and extrahepatic etiologies. As described above, intrahepatic biliary obstruction is generally called cholestasis and not covered here in detail as is not the scope of this topic.
Intrahepatic cholestasis  can be from several diseases including any form of acute hepatitis (viral, drug, alcohol), drug induced liver injury, primary biliary cholangitis, primary sclerosing cholangitis and infiltrative diseases (sarcoidosis, tumors, abscess and cysts) .
Extrahepatic biliary obstruction which is the scope of this article can have various benign and malignant etiologies. These include Choledhocholithiasis, Choledochal cysts, Mirizzi's syndrome, benign stricturing disease (PSC, iatriogenic), neoplastic stricturing disease (cholgangiocarcinoma, pancreatic head cancer, ampullary carcinomal or adenoma) and infectious diseases (Pasrasitic cholangiopathy), inflammatory and autoimmune disease (AIDS cholangiopathy, autoimmune cholangiopathy).
Incidence of gall stone causing biliary obstruction is approximately 5 in 1000 people where 10-15 % of adult US population will develop gall stones in their lifetime .
Gallstones are the most common cause of biliary obstruction in Hispanics, Northern Europeans, and Native Americans. Northern Native Americans have the highest reported rates of cholelithiasis at 64% for females and 29% for males. Asian and African Americans have intermediate prevalence of cholelithiasis with 13.9% of women and 5.3% of men. The lowest prevalence of cholelithiasis is in sub-Saharan Black Africans with an overall prevalence of less than 5%. Caucasian North Americans have an overall prevalence of cholelithiasis of 16.6% and 8.6% in females and males, respectively
The socioeconomic and demographic diversity of biliary obstruction can be evidenced in the most common cause - in developed countries of the western world, cholelithiasis secondary to cholesterol stones in the most common cause, whereas brown pigment stones in the bile ducts are most common in Asia. Oriental cholangiohepatitis which is characterized by recurrent bacterial cholangitis, dilatation, and stricturing of the biliary tree, the presence of calculi within the intrahepatic bile ducts, and an increased risk for cholangiocarcinoma is common in Asia but rare in the west. Gallbladder malignancy is more common in Central and South America, Central and Eastern Europe, the northern Indian subcontinent, and East Asia
Women are at greater risk of developing gallstones than men and hence increased risk for choledocholithiasis; likely secondary to the effect of estrogen increasing hepatic uptake of cholesterol which increases bile production
Cytology brushing and tissue biopsy to make a tissue diagnosis may be necessary for the workup for an unknown mass obstructing the biliary tract. This procedure can be performed at the time of an ERCP or by percutaneous or endoscopic ultrasound-directed biopsy.
Biliary obstruction can have very varid presentation depending on underlying etiology. It usually presents as Jaundice with clay colored stools and dark urine. Patients can have pruritis if chronic and dependin on undrlying etiology can have Right upper quadrant abdominal pain, fever, nausea and vomiting and weight loss. The onset of these symptoms can be variable ranging from acute development of symptoms to over months.
A careful history of symptom duration, gradual or acute onset, accompanying symptoms, family and social history is very important.
A detailed physical exam is of paramount importance. It is very important to check baseline vital signs, pallor and scleral icterus.
A detailed Abdominal Examination to examine for Right upper quadrant tendrness (Murphy's sign), hepatomegaly and splenomegaly, presence of ascites, any palpable mass, stigmata of cirrhosis are very crucial for diagnosis.
Cardiac exam to assess for signs of congestive heart failure with JVD elevation and displacement of heart sounds can be very important to determine underlying etiology.
Similarly, detailed lung pulmonary exam to assess for pleural effusions, determining one sided or bilateral is helpful in determing etiology.
Digital Rectal Examination
Sometimes rectal exam to assess for rectal cancer can be helpful.
Asessment of Left supraclavicular lymph node and other neck lymph nodes can provide helpful information.
Work up for biliary obstrution includes routine labs and some dedicated labs including:
Initial management depends on patients clinical condition and probable etiology. If the patient is stable, most of the work can be done as out patient with regular follow up. However if patients is febrile and shwoing signs of hepatic compromise, admitting the patient for evaluation and treatment may be needed. This is needed in patients with Acute Cholangitis, Cholecystitis and Acute Liver Failure.
Treatment varies widely for biliary obstruction depending on the underlying cause. Some common etiologies are discusssed below
Prognosis of biliary obstruction is highly dependent on the etiology. If left untreated, it can lead to life-threatening infection. If obstruction is persistent and chronic, it is usually due to a chronic liver pathology which commonly has a poor prognosis. Most acute causes can be successfully managed with medical, surgical, and/or endoscopic treatment with full recovery. Obstruction caused by chronic liver disease and carcinoma usually has a less favorable prognosis.
Most Common Cause
Prevention of recurrence
Biliary obstruction is a term encompassing many separate conditions that result in a typical clinical finding of elevated bilirubin. Patients may first present to their primary care physicians, nurse practitioner or an emergency room for treatment. The prompt initial diagnosis helps drive therapy and improve outcomes in most patients. Special attention is necessary to rule out ascending infection when patients present with findings of biliary obstruction due to the poor prognosis of ascending cholangitis and cancer. Initial laboratory and radiographic assessment will determine the proper specialty needed to treat the obstruction whether that be general surgery, gastroenterology, oncology or interventional radiology.
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