Management of bile-duct obstruction

Patients with symptoms after a cholecystectomy, particularly if jaundice is present, demand urgent investigation. Any patient who does not make an uneventful recovery following gall-bladder surgery should be investigated by ultrasound scanning as a matter of immediacy. If jaundice (either biochemical or clinical) is present emergency measures are required.

The first step in management is to undertake an immediate ultrasound scan. If there is evidence of fluid in the subhepatic space or obstruction of the biliary tree as shown by bile-duct dilatation then an immediate ERCP should be performed to ascertain whether a stone is present or there is obstruction of the common bile duct due to damage at the time of surgery (Fig. 54.41).

If a stone is present immediate removal endoscopically is indicated. If the common bile duct is obstructed by clips or there is leakage from the biliary tree due to a cystic duct leak then a drain should be placed in the subhepatic space percutaneously and a stent placed in the bile duct where possible. Small leaks will usually resolve spontaneously. Should the common bile duct be damaged the patient should be referred to an appropriate expert for reconstruction of the duct.