What Are the Most Common Causes of Chills and Fever?

Benign biliary stricture refers to bile duct scarring due to bile duct injury and recurrent cholangitis. It can be caused by iatrogenic injury, abdominal trauma, bile duct stones, and infection. Due to repeated inflammation and bile salt stimulation of the affected bile duct, fibrous tissue hyperplasia, thickening of the wall of the tube, and narrowing of the bile duct lumen resulted in pathological and clinical manifestations of biliary obstruction infection.

Basic Information

Visiting department: Gastroenterology
Common causes: Caused by iatrogenic injury, abdominal trauma, bile duct stones, and infection

Common symptoms: Dumb pain, chills, fever, jaundice, etc.
Contagious: no

Causes of benign bile duct stricture

The most common cause of benign biliary stenosis is direct or indirect biliary tract injury during cholecystectomy. The incidence of biliary tract injury is lower in open cholecystectomy. Laparoscopic cholecystectomy does not seem to reduce the incidence of biliary complications. Rising trend.

Bile duct stenosis caused by surgery is mostly fibrous scar stenosis at the site of bile duct injury, with occasional stenosis caused by other causes. Liver transplantation is also a major cause of postoperative biliary stricture. Reconstruction of the biliary tract is required after liver transplantation, and stenosis often occurs at the anastomosis of the bile duct. Chronic pancreatitis is one of the causes of benign bile duct stenosis. Due to the anatomy of the distal bile and pancreatic ducts, bile and pancreatic diseases affect each other. Chronic pancreatitis, especially chronic inflammation of the pancreatic head, often affects the end of the bile duct, causing fibrosis and stenosis of the bile duct wall. It can also cause bile duct stricture by directly compressing the common bile duct with an enlarged pancreatic head.

Invasion of some vascular diseases such as atherosclerosis, nodular polyarteritis, and hepatic artery thrombosis after hepatic artery or liver transplantation may cause bile duct blood supply disturbance, and narrowing of the bile duct in the ischemic area. In addition, upper abdominal trauma, sclerosing cholangitis, and Mirriz syndrome can also cause bile duct stenosis.

Pathogenesis of benign bile duct stricture

The damaged bile duct can be completely broken or partially defective, or it can only be squeezed or sutured by vascular forceps, which causes inflammation and fibrosis of the bile leak, and finally causes narrowing or occlusion of the bile duct. The proximal end of the narrow or occluded bile duct is dilated, and the wall is thickened. The distal wall may also be thickened, but the lumen is reduced or even occluded. After bile duct stenosis or occlusion, bile drainage is blocked, pressure in the bile duct increases, and cholestasis, if it lasts for a long time, liver cells will be irreversibly damaged; cholestasis can also be secondary to Gram-negative enterobacteria infection, causing cholangitis The repeated attacks will result in aggravated liver cell damage and cause liver cirrhosis. With biliary leakage, although liver damage can be mild, it can often be secondary to abdominal infection or bile is often lost in large quantities, causing problems in digestion and absorption.

Clinical manifestations of benign biliary stricture

1. History and symptoms

History of bile duct, epigastric surgery (trauma), or recurrent cholangitis.

(1) Obstructive jaundice or large bile overflow from the drainage port within 24 hours after the operation (injury) or early asymptomatic symptoms after the operation (injury), intermittent upper abdominal pain, chills, fever, jaundice, several weeks to years later, Stool is gray and so on.

(2) A Charcot triad may be present during an acute attack.

(3) Chronic patients have long-term jaundice, irregular fever type, deepening jaundice after fever, biliary cirrhosis, or cholangitis without jaundice. In severe cases, the condition develops rapidly and deteriorates rapidly, with severe acute cholangitis and sepsis.

2. Signs

(1) Upper abdominal tenderness during the attack.

(2) Jaundice.

(3) Hepatomegaly and tenderness.

(4) There may be signs of portal hypertension.

Benign biliary stricture

1. The number of white blood cells and neutrophils increased; the test showed obstructive jaundice; liver function was severely impaired; the ratio of white and globulin was inverted; blood culture could be positive.

2. Retrograde cholangiography, percutaneous transhepatic cholangiopancreatography, and endoscopic retrograde cholangiopancreatography (ERCP), which can show narrow areas, shapes and ranges. The bile duct is not visualized, and bile duct stricture cannot be ruled out. Sometimes intravenous biliary angiography can also show diseased bile ducts.

3. B-mode ultrasound can show the stenosis of the proximal bile duct dilatation and / or stones. Intraluminal bile duct ultrasound has special value in the diagnosis of the cause of bile duct stenosis. By the characteristics of the sonographic images of different lesions of bile duct stenosis, benign and malignant bile duct lesions can be identified.

4. Magnetic resonance cholangiopancreatography (MRCP) can correctly diagnose bile duct stenosis after liver transplantation, but compared with ERCP due to lower resolution, the details of the lesion are not clear enough, and the degree of stenosis is often exaggerated.

Diagnosis of benign bile duct stricture

Dynamic observation of alkaline phosphatase and -glutamylase and magnetic resonance cholangiopancreatography (MRCP) can make early diagnosis.

Treatment of benign biliary stricture

For most cases of traumatic bile duct stenosis, bile duct-jejunal anastomosis is a better method of bile duct reconstruction. However, due to the lack of long-term follow-up results of major cases, the exact therapeutic value of this repair technique has yet to be further evaluated, and its surgical indications need to be strictly grasped.

For cases of hepatic segment or hepatic bile duct injury that are difficult to reconstruct and secondary segmental hepatic necrosis, liver abscess, or hepatic calculi, the diseased bile duct can be removed with the affected segment of the liver. For patients with end-stage biliary disease caused by biliary cirrhosis after complex bile duct injury, liver transplantation may be the only effective method.

Endoscopy and interventional techniques are increasingly used in the diagnosis and treatment of iatrogenic bile duct injury, but the use of stenosed bile duct balloon dilatation or stent support for traumatic bile duct stenosis or postoperative biliary-enteric anastomotic stenosis cannot achieve satisfactory long-term results. There are only a few minor bile duct injuries without tissue defects. Endoscopic duodenal papillary dissection and placement of stents can be used as a definitive treatment. The most important value of endoscopic and interventional techniques in the treatment of traumatic bile duct stenosis is as an adjuvant treatment for the management of bile leakage and infection before deterministic surgery and the management of recurrent bile duct stenosis after surgery.

All patients should be treated surgically, and a few patients with poor general conditions should be actively treated non-surgically to prepare for surgery.

Indication

(1) For early fresh bile duct injuries, the stenosed segment is not long and can be anastomosed at the opposite end to support drainage for more than 1 year, but the long-term effect is not satisfied; for those who cannot be anastomosis, various types of bile-intestinal anastomosis are feasible when conditions permit. , But the bile duct-jejunum Roux-Y anastomosis is more versatile.

(2) For patients with advanced biliary stenosis or primary bile duct stenosis due to biliary tract inflammation, biliary-enteric anastomosis is also performed to remove bile duct obstruction (see Bile duct stones and cholangitis).

(3) For hepatic hilar stenosis, especially bilateral hepatic duct openings, the hilar should be dissected to reveal the hepatic duct 2cm above the stenosis, or exposed as a partial resection of the liver. The incision should span the upper and lower ends of the stenosis, if necessary, plastic surgery, enlarge the bile duct cavity, and even need to cut the common bile (liver) duct, left or (and) right hepatic duct, and anastomosis with Y-type jejunum side-to-side or end-to-side It is required to take as close as possible the stones in the proximal bile duct to improve the surgical effect.

(4) Extrahepatic bile duct stenosis can be repaired with free jejunum or gastric slices with vascular pedicles.

(5) For primary bile duct stenosis and liver disease limitation, partial resection of the liver may be performed in severe cases, often left hepatic lobe resection.

(6) If multiple lesions, accompanied by stones, and liver parenchymal damage are severe, and the bile-enteric anastomosis cannot achieve the purpose, the above-mentioned combined surgery is needed.

(7) When a few definitive repairs are not possible, the stenosed segment can be supported and fixed for a long time with a U-shaped tube, or various types of balloon catheters are used to expand the stenosed bile duct.

2. Choice of surgery timing

(1) Injuries discovered during the operation should be properly handled in a timely manner.

(2) Jaundice or peritonitis should be performed immediately after surgery. If the local inflammation is not severe, repair should be performed according to the situation. If the local inflammation is severe, it is estimated that the repair is difficult. Operate after the inflammation subsides.

(3) For advanced stenosis, especially restenosis after repair, it is advisable to perform necessary diagnostic tests, such as B-ultrasound, CT, ERCP, etc., to determine the degree and extent of the lesion, and then to perform definitive surgery.

3. Choice of surgical method

For iatrogenic bile duct stenosis, stenotic scar removal and bile duct anastomosis have been abandoned in recent years due to its high restenosis rate. After longitudinal incision of the narrow section, vascularized jejunal flap, gastric wall flap, round ligament, etc. are used for repair. Occasionally, there are reports in the literature, which can be selected according to the situation. Roux-en-Y anastomosis with stenosed proximal bile ducts and jejunum is now used.