What is included in medical care for biliary obstruction?

Updated: Oct 16, 2019
  • Author: Jennifer Lynn Bonheur, MD; Chief Editor: Vinay Kumar Kapoor, MBBS, MS, FRCS, FAMS  more...
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Answer

In cases of cholelithiasis in which either the patient refuses surgery or surgical intervention is not appropriate, an attempt to dissolve noncalcified calculi may occasionally be made by the administration of oral bile salts for as long as 2 years.

Because gallbladder emptying is an important determinant of stone clearance, normal gallbladder function must first be established via oral cholecystography.

Ursodeoxycholic acid (10 mg/kg/d) works to reduce biliary secretion of cholesterol. In turn, this decreases the cholesterol saturation of bile. In 30-40% of patients, this results in the gradual dissolution of cholesterol-containing stones. However, stones may recur within 5 years once the drug is stopped (50% of patients).

Extracorporeal shock-wave lithotripsy may be used as an adjunct to oral dissolution therapy. By increasing the surface-to-volume ratio of the stones, it both enhances dissolution of stones and makes clearing the smaller fragments easier. Contraindications include complications of gallstone disease (eg, cholecystitis, choledocholelithiasis, biliary pancreatitis), pregnancy, and coagulopathy or anticoagulant medications (ie, because of the risk of hematoma formation). Lithotripsy is associated with a 70% recurrence rate for gallstones, is not approved by the US Food and Drug Association, and is restricted to investigational programs only.

In cases of malignant biliary obstruction, a meta-analysis suggests that endoscopic nasobiliary drainage (ENBD) is more effective and safe than endoscopic biliary stenting (EBS) with regard to preoperative and postoperative complications such as the postoperative pancreatic fistula rate, the incidence of stent dysfunction, and morbidity. [15] However, the meta-analysis did not include data from randomized controlled trials.


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