BILE DUCT STRICTURES

1. Chief complaint
•Bile duct strictures
2. HPI
a. Concern:
b. Onset-
•Sudden
•Gradual

c. Duration: ____
•Recent
•A few days
•Many days
•A few weeks
•Many weeks
•A few months
•Many months
•A few years
•Many years
•Recurrent
•N/A.

d. Severity:
•Mild
•Moderate
•Severe
•Absent
•Normal
•Increased
•Decreased
•Stable
•No significant change from prior visit.
•Details

e. Location: Right upper quadrant

f. Radiation:
•The flanks
•Intrascapular regions
•Right shoulder
 g. Quality:
•Improving
•No change
•Worsening
•Burning pain
•Constricting
•Crushing
•Dull pain
•Heavy
•Sharp pain
•Squeezing
•Stabbing

h. Frequancy
i. Status
j. Context
k. Aggravated by :
l. Relieved by
m. Associated Symptoms
n. Pertinent Negatives
o. Notes

3. ROS

4. SYMPTOMS

•Right upper quadrant pain

•Right upper abdominal discomfort
•Pruritus
•Yellow discoloration of skin
•Steatorrhea
•Anorexia
•Nausea
•Vomiting
•Cachexia s

5. HISTORY

a. FAMILY HISTORY
•Diabetes
•Obesity
b. SOCIAL HISTORY
 •Alcoholism
c. PAST MEDICAL HISTORY
•Pancreatitis
•Bile duct stones
•Tuberculosis
•histoplasmosis
•Pancreatic cancer
•Mucinous cystadenocarcinoma
•Ampullary carcinoma
•Gallbladder carcinoma
•Cholangiocarcinoma
•Hepatocellular cancer

d. SURGICAL HISTORY
•Cholecystectomy
•Gastrectomy
•Pancreatic surgery
•Hepatic and portal vein surgery
•Orthotopic liver transplantation

e. CHRONIC CONDITIONS
•primary sclerosing cholangitis

6. ALLERGIES

7. PHYSICAL EXAMINATION
•Mild right upper quadrant tenderness

8. SPECIFIC DATA LIKE GRADING

BISMUTH PROPOSED AN ANATOMIC CLASSIFICATION OF BILE

DUCT STRICTURES

o Type 1: This is a low common hepatic duct stricture. At least 2

cm of the hepatic duct is intact.
o Type 2: This is a mid common hepatic duct stricture. The hepatic
duct stump is smaller than 2 cm.
o Type 3: This is a hilar stricture. The common hepatic duct is not
involved, but the confluence of right and left hepatic ducts is
intact.
o Type 4: In this type, the hilar confluence is destroyed. The right
and left hepatic ducts are separated.
o Type 5: The aberrant right sectorial duct is involved, alone or
with the CBD.

9. TESTS TO BE ORDERED
a. Liver profile
b. CBC
c. Helicobacter pylori serology
d. WBC count
e. Alkaline phosphatase
f. Bilirubin
g. prothrombin time
h. Gamma-glutamyl transpeptidase
i. Alanine aminotransferase (ALT)
j. Aspartate aminotransferase (AST)
k. Amylase/lipase assays
l. Liver function tests
m. CRP (C-reactive protein)
n. Urinalysis
o. Radiography (without contrast) abdomen
p. USG abdomen
q. Cholangiography
r. Percutaneous transhepatic cholangiography (PTC)
s. CT scan
t. MRI
u. Hepatobiliary scintigraphy
v. Fistulography
w. Endoscopic retrograde cholangiopancreatography (ERCP)
x. Endoscopic ultrasound-guided transmural cholecystostomy

10. ASSESSMENT/PLAN

•Endoscopic or percutaneous balloon dilatation and

insertion of an endoprosthesis
•Sphincterotomy and endoscopic balloon dilation
•Endoscopic therapy for PSC
•Biliary-enteric anastomosis

11. EDUCATION
•Avoid fat rich diet

12. MEDICATION
 •Piperacillin
•Tazobactam sodium
•Imipenem
•Cilastatin
•Metronidazole
•Gentamicin
•Penicillin G

13. FOLLOW UP