Bile duct stricture is defined by a narrowing of the bile duct, most often seen on ultrasound or cross-sectional imaging (CT or MRI). The etiology of bile duct strictures can be benign (approximately 30% of cases) or malignant. With a high prevalence of underlying malignancy, these findings must be addressed with an expedited diagnostic work-up, as suspected malignant etiologies will often require surgical intervention and have a high risk of pre-diagnosis metastatic spread.

Patients can present with a wide range of symptoms. Some present with painless jaundice, while others present with obstructive jaundice and cholangitis (right upper quadrant pain, jaundice, fever, and sepsis).

In some circumstances, bile duct stricture can be found incidentally on imaging.

Lab findings can be normal or can demonstrate degrees of biliary obstruction (elevated alkaline phosphatase, elevated alanine transaminase [ALT] / aspartate transaminase [AST], elevated direct bilirubin). Tumor markers (CA 19-9, CEA) can be positive when the bile duct stricture is due to an underlying malignancy, most commonly either cholangiocarcinoma or pancreatic adenocarcinoma.

Diagnosis is often established by endoscopic retrograde cholangiopancreatography (ERCP) or endoscopic ultrasound (EUS) with fine needle aspiration, both modalities leading to a pathologic diagnosis. ERCP is indicated with evidence of obstructive jaundice; otherwise, EUS with fine needle aspiration is preferred.

Treatment depends on the etiology causing the stricture. For malignancies, surgical resection is often attempted. For benign etiologies, biliary stenting and/or treatment of the underlying cause (ie, steroids for autoimmune pancreatitis) is recommended.