Radiologic Management of Biliary Obstruction

Variant: 1 Initial therapeutic procedure for a patient with dilated bile ducts from choledocholithiasis.

Procedure	Appropriateness Category
Endoscopic internal biliary catheter (removable plastic stent)	Usually Appropriate
Percutaneous internal/external biliary catheter	May Be Appropriate
Endoscopic US-guided biliary drainage (EUS-BD)	May Be Appropriate
Removable biliary covered stent	May Be Appropriate
Medical management only	Usually Not Appropriate
Surgery	Usually Not Appropriate
Permanent biliary metallic stent	Usually Not Appropriate

Variant: 2 Initial therapeutic procedure for a patient with elevated bilirubin and suspected sclerosing cholangitis.

Procedure	Appropriateness Category
Endoscopic internal biliary catheter (removable plastic stent)	Usually Appropriate
Medical management only	May Be Appropriate
Percutaneous internal/external biliary catheter	May Be Appropriate
Removable biliary covered stent	Usually Not Appropriate
Surgery	Usually Not Appropriate
Permanent biliary metallic stent	Usually Not Appropriate

Variant: 3 Initial therapeutic procedure for a liver transplant recipient with elevated bilirubin and suspected biliary anastomotic stenosis or bile leak, with no dilated ducts.

Procedure	Appropriateness Category
Endoscopic internal biliary catheter (removable plastic stent)	Usually Appropriate
Percutaneous internal/external biliary catheter	Usually Appropriate
Removable biliary covered stent	May Be Appropriate
Endoscopic US-guided biliary drainage (EUS-BD)	Usually Not Appropriate
Surgery	Usually Not Appropriate
Medical management only	Usually Not Appropriate
Permanent biliary metallic stent	Usually Not Appropriate

Variant: 4 Initial therapeutic procedure for a patient with bile leak and dilated bile ducts following laparoscopic cholecystectomy.

Procedure	Appropriateness Category
Endoscopic internal biliary catheter (removable plastic stent)	Usually Appropriate
Percutaneous internal/external biliary catheter	Usually Appropriate
Surgery	May Be Appropriate
Endoscopic US-guided biliary drainage (EUS-BD)	Usually Not Appropriate
Medical management only	Usually Not Appropriate
Permanent biliary metallic stent	Usually Not Appropriate
Removable biliary covered stent	Usually Not Appropriate

Variant: 5 Initial therapeutic procedure for a patient with dilated bile ducts and suspected biliary sepsis or acute cholangitis.

Procedure	Appropriateness Category
Endoscopic internal biliary catheter (removable plastic stent)	Usually Appropriate
Percutaneous internal/external biliary catheter	Usually Appropriate
Endoscopic US-guided biliary drainage (EUS-BD)	May Be Appropriate
Medical management only	Usually Not Appropriate
Removable biliary covered stent	Usually Not Appropriate
Surgery	Usually Not Appropriate
Permanent biliary metallic stent	Usually Not Appropriate

Variant: 6 Initial therapeutic procedure for a patient with malignant common bile duct obstruction (eg, pancreatic carcinoma).

Procedure	Appropriateness Category
Endoscopic internal biliary catheter (removable plastic stent)	Usually Appropriate
Percutaneous internal/external biliary catheter	Usually Appropriate
Percutaneous biliary metallic stent	May Be Appropriate
Removable biliary covered stent	May Be Appropriate
Surgery	May Be Appropriate
Endoscopic US-guided biliary drainage (EUS-BD)	May Be Appropriate
Medical management only	Usually Not Appropriate

Variant: 7 Initial therapeutic procedure for a patient with hilar biliary obstruction from malignant etiology (eg, Klatskin tumor).

Procedure	Appropriateness Category
Percutaneous internal/external biliary catheter	Usually Appropriate
Endoscopic internal biliary catheter (removable plastic stent)	May Be Appropriate
Permanent biliary metallic stent	May Be Appropriate
Removable biliary covered stent	May Be Appropriate
Surgery	May Be Appropriate
Endoscopic US-guided biliary drainage (EUS-BD)	Usually Not Appropriate
Medical management only	Usually Not Appropriate

Variant: 8 Initial therapeutic procedure for a patient with dilated bile ducts and coagulopathy (INR >2.0 or platelet count <60 K).

Procedure	Appropriateness Category
Endoscopic internal biliary catheter (removable plastic stent)	Usually Appropriate
Percutaneous internal/external biliary catheter	May Be Appropriate
Medical management only	May Be Appropriate
Endoscopic US-guided biliary drainage (EUS-BD)	Usually Not Appropriate
Removable biliary covered stent	Usually Not Appropriate
Surgery	Usually Not Appropriate
Permanent biliary metallic stent	Usually Not Appropriate

Variant: 9 Initial therapeutic procedure for a patient with dilated bile ducts and moderate to massive ascites.

Procedure	Appropriateness Category
Endoscopic internal biliary catheter (removable plastic stent)	Usually Appropriate
Percutaneous internal/external biliary catheter	May Be Appropriate
Medical management only	May Be Appropriate
Removable biliary covered stent	May Be Appropriate
Endoscopic US-guided biliary drainage (EUS-BD)	Usually Not Appropriate
Permanent biliary metallic stent	Usually Not Appropriate
Surgery	Usually Not Appropriate

Panel Members

Eric J. Hohenwalter, MD^a; Alexandra H. Fairchild, MD^b; Matthew G. Gipson, MD^c; Waddah B. Al-Refaie, MD^d; Aaron R. Braun, MD^e; Brooks D. Cash, MD^f; Charles Y. Kim, MD^g; Jason W. Pinchot, MD^h; Matthew J. Scheidt, MDⁱ; Kristofer Schramm, MD^j; David M. Sella, MD^k; Clifford R. Weiss, MD^l; Jonathan M. Lorenz, MD^m.

Summary of Literature Review

Introduction/Background

Discussion of Procedures by Variant

Variant 1: Initial therapeutic procedure for a patient with dilated bile ducts from choledocholithiasis.

Variant 1: Initial therapeutic procedure for a patient with dilated bile ducts from choledocholithiasis.
A. Medical management only

Variant 1: Initial therapeutic procedure for a patient with dilated bile ducts from choledocholithiasis.
B. Percutaneous internal/external biliary catheter

Variant 1: Initial therapeutic procedure for a patient with dilated bile ducts from choledocholithiasis.
C. Permanent biliary metallic stent

Variant 1: Initial therapeutic procedure for a patient with dilated bile ducts from choledocholithiasis.
D. Removable biliary covered stent

Variant 2: Initial therapeutic procedure for a patient with elevated bilirubin and suspected sclerosing cholangitis.

Variant 2: Initial therapeutic procedure for a patient with elevated bilirubin and suspected sclerosing cholangitis.
A. Endoscopic internal biliary catheter (removable plastic stent)

Variant 2: Initial therapeutic procedure for a patient with elevated bilirubin and suspected sclerosing cholangitis.
B. Medical management only

Variant 2: Initial therapeutic procedure for a patient with elevated bilirubin and suspected sclerosing cholangitis.
C. Percutaneous internal/external biliary catheter

Variant 3: Initial therapeutic procedure for a liver transplant recipient with elevated bilirubin and suspected biliary anastomotic stenosis or bile leak, with no dilated ducts.

Variant 3: Initial therapeutic procedure for a liver transplant recipient with elevated bilirubin and suspected biliary anastomotic stenosis or bile leak, with no dilated ducts.
A. Endoscopic internal biliary catheter (removable plastic stent)

Variant 3: Initial therapeutic procedure for a liver transplant recipient with elevated bilirubin and suspected biliary anastomotic stenosis or bile leak, with no dilated ducts.
B. Endoscopic US-guided biliary drainage (EUS-BD)

Variant 4: Initial therapeutic procedure for a patient with bile leak and dilated bile ducts following laparoscopic cholecystectomy.

Variant 4: Initial therapeutic procedure for a patient with bile leak and dilated bile ducts following laparoscopic cholecystectomy.
A. Endoscopic internal biliary catheter (removable plastic stent)

Variant 4: Initial therapeutic procedure for a patient with bile leak and dilated bile ducts following laparoscopic cholecystectomy.
B. Endoscopic US-guided biliary drainage (EUS-BD)

Variant 4: Initial therapeutic procedure for a patient with bile leak and dilated bile ducts following laparoscopic cholecystectomy.
C. Medical management only

Variant 4: Initial therapeutic procedure for a patient with bile leak and dilated bile ducts following laparoscopic cholecystectomy.
D. Percutaneous internal/external biliary catheter

Variant 5: Initial therapeutic procedure for a patient with dilated bile ducts and suspected biliary sepsis or acute cholangitis.

Variant 5: Initial therapeutic procedure for a patient with dilated bile ducts and suspected biliary sepsis or acute cholangitis.
A. Endoscopic internal biliary catheter (removable plastic stent)

Variant 5: Initial therapeutic procedure for a patient with dilated bile ducts and suspected biliary sepsis or acute cholangitis.
B. Endoscopic US-guided biliary drainage (EUS-BD)

Variant 5: Initial therapeutic procedure for a patient with dilated bile ducts and suspected biliary sepsis or acute cholangitis.
C. Medical management only

Variant 5: Initial therapeutic procedure for a patient with dilated bile ducts and suspected biliary sepsis or acute cholangitis.
D. Percutaneous internal/external biliary catheter

Variant 5: Initial therapeutic procedure for a patient with dilated bile ducts and suspected biliary sepsis or acute cholangitis.
E. Permanent biliary metallic stent

Variant 6: Initial therapeutic procedure for a patient with malignant common bile duct obstruction (eg, pancreatic carcinoma).

Variant 6: Initial therapeutic procedure for a patient with malignant common bile duct obstruction (eg, pancreatic carcinoma).
A. Endoscopic internal biliary catheter (removable plastic stent)

Variant 6: Initial therapeutic procedure for a patient with malignant common bile duct obstruction (eg, pancreatic carcinoma).
B. Endoscopic US-guided biliary drainage (EUS-BD)

Variant 6: Initial therapeutic procedure for a patient with malignant common bile duct obstruction (eg, pancreatic carcinoma).
C. Medical management only

Variant 6: Initial therapeutic procedure for a patient with malignant common bile duct obstruction (eg, pancreatic carcinoma).
D. Percutaneous biliary metallic stent

Variant 6: Initial therapeutic procedure for a patient with malignant common bile duct obstruction (eg, pancreatic carcinoma).
E. Percutaneous internal/external biliary catheter

Variant 7: Initial therapeutic procedure for a patient with hilar biliary obstruction from malignant etiology (eg, Klatskin tumor).

Variant 7: Initial therapeutic procedure for a patient with hilar biliary obstruction from malignant etiology (eg, Klatskin tumor).
A. Endoscopic internal biliary catheter (removable plastic stent)

Variant 7: Initial therapeutic procedure for a patient with hilar biliary obstruction from malignant etiology (eg, Klatskin tumor).
B. Endoscopic US-guided biliary drainage (EUS-BD)

Variant 7: Initial therapeutic procedure for a patient with hilar biliary obstruction from malignant etiology (eg, Klatskin tumor).
C. Medical management only

Variant 8: Initial therapeutic procedure for a patient with dilated bile ducts and coagulopathy (INR >2.0 or platelet count <60 K).

Variant 8: Initial therapeutic procedure for a patient with dilated bile ducts and coagulopathy (INR >2.0 or platelet count <60 K).
A. Endoscopic internal biliary catheter (removable plastic stent)

Variant 8: Initial therapeutic procedure for a patient with dilated bile ducts and coagulopathy (INR >2.0 or platelet count <60 K).
B. Endoscopic US-guided biliary drainage (EUS-BD)

Variant 9: Initial therapeutic procedure for a patient with dilated bile ducts and moderate to massive ascites.

Variant 9: Initial therapeutic procedure for a patient with dilated bile ducts and moderate to massive ascites.
A. Endoscopic internal biliary catheter (removable plastic stent)

Variant 9: Initial therapeutic procedure for a patient with dilated bile ducts and moderate to massive ascites.
B. Endoscopic US-guided biliary drainage (EUS-BD)

Variant 9: Initial therapeutic procedure for a patient with dilated bile ducts and moderate to massive ascites.
C. Medical management only

Summary of Recommendations

Supporting Documents

The evidence table, literature search, and appendix for this topic are available at https://acsearch.acr.org/list. The appendix includes the strength of evidence assessment and the final rating round tabulations for each recommendation.

For additional information on the Appropriateness Criteria methodology and other supporting documents, please go to the ACR website at https://www.acr.org/Clinical-Resources/Clinical-Tools-and-Reference/Appropriateness-Criteria.

Appropriateness Category Names and Definitions

Appropriateness Category Name	Appropriateness Rating	Appropriateness Category Definition
Usually Appropriate	7, 8, or 9	The imaging procedure or treatment is indicated in the specified clinical scenarios at a favorable risk-benefit ratio for patients.
May Be Appropriate	4, 5, or 6	The imaging procedure or treatment may be indicated in the specified clinical scenarios as an alternative to imaging procedures or treatments with a more favorable risk-benefit ratio, or the risk-benefit ratio for patients is equivocal.
May Be Appropriate (Disagreement)	5	The individual ratings are too dispersed from the panel median. The different label provides transparency regarding the panel’s recommendation. “May be appropriate” is the rating category and a rating of 5 is assigned.
Usually Not Appropriate	1, 2, or 3	The imaging procedure or treatment is unlikely to be indicated in the specified clinical scenarios, or the risk-benefit ratio for patients is likely to be unfavorable.

References

1.	Hortobagyi GN. Treatment of breast cancer. N Engl J Med. 1998;339(14):974-984.
2.	Rougier P, Van Cutsem E, Bajetta E, et al. Randomised trial of irinotecan versus fluorouracil by continuous infusion after fluorouracil failure in patients with metastatic colorectal cancer. Lancet. 1998;352(9138):1407-1412.
3.	American College of Radiology. ACR Appropriateness Criteria®: Jaundice. Available at: https://acsearch.acr.org/docs/69497/Narrative/.
4.	Stinton LM, Shaffer EA. Epidemiology of gallbladder disease: cholelithiasis and cancer. Gut Liver. 2012;6(2):172-187.
5.	Huang RJ, Thosani NC, Barakat MT, et al. Evolution in the utilization of biliary interventions in the United States: results of a nationwide longitudinal study from 1998 to 2013. Gastrointest Endosc. 2017;86(2):319-326 e315.
6.	Bodger K, Bowering K, Sarkar S, Thompson E, Pearson MG. All-cause mortality after first ERCP in England: clinically guided analysis of hospital episode statistics with linkage to registry of death. Gastrointest Endosc. 2011;74(4):825-833.
7.	Cerefice M, Sauer B, Javaid M, et al. Complex biliary stones: treatment with removable self-expandable metal stents: a new approach (with videos). Gastrointest Endosc. 2011;74(3):520-526.
8.	Vaira D, D'Anna L, Ainley C, et al. Endoscopic sphincterotomy in 1000 consecutive patients. Lancet. 1989;2(8660):431-434.
9.	Copelan A, Kapoor BS. Choledocholithiasis: Diagnosis and Management. Tech Vasc Interv Radiol. 2015;18(4):244-255.
10.	Chopra KB, Peters RA, O'Toole PA, et al. Randomised study of endoscopic biliary endoprosthesis versus duct clearance for bileduct stones in high-risk patients. Lancet. 1996;348(9030):791-793.
11.	Bakhru MR, Kahaleh M. Expandable metal stents for benign biliary disease. Gastrointest Endosc Clin N Am. 2011;21(3):447-462, viii.
12.	Ge N, Wang S, Wang G, et al. Endoscopic ultrasound-assisted cholecystogastrostomy by a novel fully covered metal stent for the treatment of gallbladder stones. Endosc Ultrasound. 2015;4(2):152-155.
13.	Hintze RE, Veltzke W, Adler A, Abou-Rebyeh H. Endoscopic sphincterotomy using an S-shaped sphincterotome in patients with a Billroth II or Roux-en-Y gastrojejunostomy. Endoscopy. 1997;29(2):74-78.
14.	Wright BE, Cass OW, Freeman ML. ERCP in patients with long-limb Roux-en-Y gastrojejunostomy and intact papilla. Gastrointest Endosc. 2002;56(2):225-232.
15.	Siddiqui AA, Mehendiratta V, Loren D, et al. Self-expanding metal stents (SEMS) for preoperative biliary decompression in patients with resectable and borderline-resectable pancreatic cancer: outcomes in 241 patients. Dig Dis Sci. 2013;58(6):1744-1750.
16.	Emmett DS, Mallat DB. Double-balloon ERCP in patients who have undergone Roux-en-Y surgery: a case series. Gastrointest Endosc. 2007;66(5):1038-1041.
17.	Kurzynske FC, Romagnuolo J, Brock AS. Success of single-balloon enteroscopy in patients with surgically altered anatomy. Gastrointestinal Endoscopy. 82(2):319-24, 2015 Aug.
18.	Wang AY, Sauer BG, Behm BW, et al. Single-balloon enteroscopy effectively enables diagnostic and therapeutic retrograde cholangiography in patients with surgically altered anatomy. Gastrointest Endosc. 2010;71(3):641-649.
19.	Zouhairi ME, Watson JB, Desai SV, et al. Rotational assisted endoscopic retrograde cholangiopancreatography in patients with reconstructive gastrointestinal surgical anatomy. World J Gastrointest Endosc. 2015;7(3):278-282.
20.	Shah RJ, Smolkin M, Yen R, et al. A multicenter, U.S. experience of single-balloon, double-balloon, and rotational overtube-assisted enteroscopy ERCP in patients with surgically altered pancreaticobiliary anatomy (with video). Gastrointest Endosc. 2013;77(4):593-600.
21.	Skinner M, Popa D, Neumann H, Wilcox CM, Monkemuller K. ERCP with the overtube-assisted enteroscopy technique: a systematic review. Endoscopy. 2014;46(7):560-572.
22.	Garcia-Garcia L, Lanciego C. Percutaneous treatment of biliary stones: sphincteroplasty and occlusion balloon for the clearance of bile duct calculi. AJR Am J Roentgenol. 2004;182(3):663-670.
23.	Pessa ME, Hawkins IF, Vogel SB. The treatment of acute cholangitis. Percutaneous transhepatic biliary drainage before definitive therapy. Ann Surg. 1987;205(4):389-392.
24.	Ilgit ET, Gurel K, Onal B. Percutaneous management of bile duct stones. Eur J Radiol. 2002;43(3):237-245.
25.	Ozcan N, Kahriman G, Mavili E. Percutaneous transhepatic removal of bile duct stones: results of 261 patients. Cardiovasc Intervent Radiol. 2012;35(4):890-897.
26.	Calvo MM, Bujanda L, Heras I, et al. The rendezvous technique for the treatment of choledocholithiasis. Gastrointest Endosc. 2001;54(4):511-513.
27.	Okuno M, Iwashita T, Yasuda I, et al. Percutaneous transgallbladder rendezvous for enteroscopic management of choledocholithiasis in patients with surgically altered anatomy. Scand J Gastroenterol. 2013;48(8):974-978.
28.	Dasari BV, Tan CJ, Gurusamy KS, et al. Surgical versus endoscopic treatment of bile duct stones. Cochrane Database Syst Rev. 2013(9):CD003327.
29.	Alkhatib AA, Hilden K, Adler DG. Comorbidities, sphincterotomy, and balloon dilation predict post-ERCP adverse events in PSC patients: operator experience is protective. Dig Dis Sci. 56(12):3685-8, 2011 Dec.
30.	Smith T, Befeler AS. High-dose ursodeoxycholic acid for the treatment of primary sclerosing cholangitis. Curr Gastroenterol Rep. 2007;9(1):54-59.
31.	Shenoy SM, Shenoy S, Gopal S, Tantry BV, Baliga S, Jain A. Clinicomicrobiological analysis of patients with cholangitis. Indian J Med Microbiol. 2014;32(2):157-160.
32.	Tabibian JH, Gossard A, El-Youssef M, et al. Prospective Clinical Trial of Rifaximin Therapy for Patients With Primary Sclerosing Cholangitis. Am J Ther. 2017;24(1):e56-e63.
33.	Rahimpour S, Nasiri-Toosi M, Khalili H, Ebrahimi-Daryani N, Nouri-Taromlou MK, Azizi Z. A Triple Blinded, Randomized, Placebo-Controlled Clinical Trial to Evaluate the Efficacy and Safety of Oral Vancomycin in Primary Sclerosing Cholangitis: a Pilot Study. J Gastrointestin Liver Dis. 2016;25(4):457-464.
34.	Farkkila M, Karvonen AL, Nurmi H, et al. Metronidazole and ursodeoxycholic acid for primary sclerosing cholangitis: a randomized placebo-controlled trial. Hepatology. 2004;40(6):1379-1386.
35.	Aljiffry M, Renfrew PD, Walsh MJ, Laryea M, Molinari M. Analytical review of diagnosis and treatment strategies for dominant bile duct strictures in patients with primary sclerosing cholangitis. HPB (Oxford). 2011;13(2):79-90.
36.	Hammel P, Couvelard A, O'Toole D, et al. Regression of liver fibrosis after biliary drainage in patients with chronic pancreatitis and stenosis of the common bile duct. N Engl J Med. 2001;344(6):418-423.
37.	May GR, Bender CE, LaRusso NF, Wiesner RH. Nonoperative dilatation of dominant strictures in primary sclerosing cholangitis. AJR Am J Roentgenol. 1985;145(5):1061-1064.
38.	Chapman MH, Webster GJ, Bannoo S, Johnson GJ, Wittmann J, Pereira SP. Cholangiocarcinoma and dominant strictures in patients with primary sclerosing cholangitis: a 25-year single-centre experience. Eur J Gastroenterol Hepatol. 2012;24(9):1051-1058.
39.	Ponsioen CY, Lam K, van Milligen de Wit AW, Huibregtse K, Tytgat GN. Four years experience with short term stenting in primary sclerosing cholangitis. Am J Gastroenterol. 1999;94(9):2403-2407.
40.	Cote GA, Kumar N, Ansstas M, et al. Risk of post-ERCP pancreatitis with placement of self-expandable metallic stents. Gastrointest Endosc. 2010;72(4):748-754.
41.	Ahrendt SA, Pitt HA, Kalloo AN, et al. Primary sclerosing cholangitis: resect, dilate, or transplant? Ann Surg. 1998;227(3):412-423.
42.	Pawlik TM, Olbrecht VA, Pitt HA, et al. Primary sclerosing cholangitis: role of extrahepatic biliary resection. J Am Coll Surg. 2008;206(5):822-830; discussion 830-822.
43.	Tsai S, Pawlik TM. Primary sclerosing cholangitis: the role of extrahepatic biliary resection. Adv Surg. 2009;43:175-188.
44.	Baccarani U, Risaliti A, Zoratti L, et al. Role of endoscopic retrograde cholangiopancreatography in the diagnosis and treatment of biliary tract complications after orthotopic liver transplantation. Dig Liver Dis. 2002;34(8):582-586.
45.	Fleck A, Zanotelli ML, Meine M, et al. Biliary tract complications after orthotopic liver transplantation in adult patients. Transplant Proc. 2002;34(2):519-520.
46.	Memeo R, Piardi T, Sangiuolo F, Sommacale D, Pessaux P. Management of biliary complications after liver transplantation. World J Hepatol. 2015;7(29):2890-2895.
47.	Gastaca M. Biliary complications after orthotopic liver transplantation: a review of incidence and risk factors. Transplant Proc. 2012;44(6):1545-1549.
48.	Thuluvath PJ, Pfau PR, Kimmey MB, Ginsberg GG. Biliary complications after liver transplantation: the role of endoscopy. Endoscopy. 2005;37(9):857-863.
49.	Gwon DI, Sung KB, Ko GY, Yoon HK, Lee SG. Dual catheter placement technique for treatment of biliary anastomotic strictures after liver transplantation. Liver Transpl. 2011;17(2):159-166.
50.	Kulaksiz H, Weiss KH, Gotthardt D, et al. Is stenting necessary after balloon dilation of post-transplantation biliary strictures? Results of a prospective comparative study. Endoscopy. 2008;40(9):746-751.
51.	Aparicio D, Otoch JP, Montero EFS, Khan MA, Artifon ELA. Endoscopic approach for management of biliary strictures in liver transplant recipients: A systematic review and meta-analysis. United European Gastroenterol J. 2017;5(6):827-845.
52.	Kaffes A, Griffin S, Vaughan R, et al. A randomized trial of a fully covered self-expandable metallic stent versus plastic stents in anastomotic biliary strictures after liver transplantation. Therap Adv Gastroenterol. 2014;7(2):64-71.
53.	Hisatsune H, Yazumi S, Egawa H, et al. Endoscopic management of biliary strictures after duct-to-duct biliary reconstruction in right-lobe living-donor liver transplantation. Transplantation. 2003;76(5):810-815.
54.	Wadhawan M, Kumar A. Management issues in post living donor liver transplant biliary strictures. World J Hepatol. 2016;8(10):461-470.
55.	Lee SH, Ryu JK, Woo SM, et al. Optimal interventional treatment and long-term outcomes for biliary stricture after liver transplantation. Clin Transplant. 2008;22(4):484-493.
56.	Wadhawan M, Kumar A, Gupta S, et al. Post-transplant biliary complications: an analysis from a predominantly living donor liver transplant center. J Gastroenterol Hepatol. 2013;28(6):1056-1060.
57.	Rieber A, Brambs HJ, Lauchart W. The radiological management of biliary complications following liver transplantation. Cardiovasc Intervent Radiol. 1996;19(4):242-247.
58.	Righi D, Cesarani F, Muraro E, Gazzera C, Salizzoni M, Gandini G. Role of interventional radiology in the treatment of biliary strictures following orthotopic liver transplantation. Cardiovasc Intervent Radiol. 2002;25(1):30-35.
59.	Stratta RJ, Wood RP, Langnas AN, et al. Diagnosis and treatment of biliary tract complications after orthotopic liver transplantation. Surgery. 1989;106(4):675-683; discussion 683-674.
60.	Flum DR, Cheadle A, Prela C, Dellinger EP, Chan L. Bile duct injury during cholecystectomy and survival in medicare beneficiaries. JAMA. 2003;290(16):2168-2173.
61.	Thompson CM, Saad NE, Quazi RR, Darcy MD, Picus DD, Menias CO. Management of iatrogenic bile duct injuries: role of the interventional radiologist. [Review]. Radiographics. 33(1):117-34, 2013 Jan-Feb.
62.	Lau WY, Lai EC, Lau SH. Management of bile duct injury after laparoscopic cholecystectomy: a review. ANZ J Surg. 2010;80(1-2):75-81.
63.	Bismuth H. Postoperative strictures of the bile ducts. In: Blumgart LH, ed. The Biliary Tract V. New York, NY: Churchill-Livingstone; 1982:209-218.
64.	Strasberg SM, Hertl M, Soper NJ. An analysis of the problem of biliary injury during laparoscopic cholecystectomy. J Am Coll Surg. 1995;180(1):101-125.
65.	Bektas H, Schrem H, Winny M, Klempnauer J. Surgical treatment and outcome of iatrogenic bile duct lesions after cholecystectomy and the impact of different clinical classification systems. Br J Surg. 2007;94(9):1119-1127.
66.	Weber A, Feussner H, Winkelmann F, Siewert JR, Schmid RM, Prinz C. Long-term outcome of endoscopic therapy in patients with bile duct injury after cholecystectomy. J Gastroenterol Hepatol. 2009;24(5):762-769.
67.	Barbier L, Souche R, Slim K, Ah-Soune P. Long-term consequences of bile duct injury after cholecystectomy. J Visc Surg. 2014;151(4):269-279.
68.	Misra S, Melton GB, Geschwind JF, Venbrux AC, Cameron JL, Lillemoe KD. Percutaneous management of bile duct strictures and injuries associated with laparoscopic cholecystectomy: a decade of experience. J Am Coll Surg. 2004;198(2):218-226.
69.	Saad WE, Darcy MD. Percutaneous management of biliary leaks: biliary embosclerosis and ablation. Tech Vasc Interv Radiol. 2008;11(2):111-119.
70.	Draganov P, Hoffman B, Marsh W, Cotton P, Cunningham J. Long-term outcome in patients with benign biliary strictures treated endoscopically with multiple stents. Gastrointest Endosc. 2002;55(6):680-686.
71.	Tringali A, Blero D, Boskoski I, et al. Difficult removal of fully covered self expandable metal stents (SEMS) for benign biliary strictures: the "SEMS in SEMS" technique. Dig Liver Dis. 2014;46(6):568-571.
72.	Huang T, Bass JA, Williams RD. The significance of biliary pressure in cholangitis. Arch Surg. 1969;98(5):629-632.
73.	Mayumi T, Okamoto K, Takada T, et al. Tokyo Guidelines 2018: management bundles for acute cholangitis and cholecystitis. J Hepatobiliary Pancreat Sci. 2018;25(1):96-100.
74.	Gomi H, Takada T, Hwang TL, et al. Updated comprehensive epidemiology, microbiology, and outcomes among patients with acute cholangitis. J Hepatobiliary Pancreat Sci. 2017;24(6):310-318.
75.	Boey JH, Way LW. Acute cholangitis. Ann Surg. 1980;191(3):264-270.
76.	van den Hazel SJ, Speelman P, Tytgat GN, Dankert J, van Leeuwen DJ. Role of antibiotics in the treatment and prevention of acute and recurrent cholangitis. Clin Infect Dis. 1994;19(2):279-286.
77.	Kiriyama S, Takada T, Hwang TL, et al. Clinical application and verification of the TG13 diagnostic and severity grading criteria for acute cholangitis: an international multicenter observational study. J Hepatobiliary Pancreat Sci. 24(6):329-337, 2017 Jun.
78.	Park CS, Jeong HS, Kim KB, et al. Urgent ERCP for acute cholangitis reduces mortality and hospital stay in elderly and very elderly patients. Hepatobiliary Pancreat Dis Int. 15(6):619-625, 2016 Dec.
79.	Lai EC, Chu KM, Lo CY, Fan ST, Lo CM, Wong J. Choice of palliation for malignant hilar biliary obstruction. Am J Surg. 1992;163(2):208-212.
80.	Sugiyama M, Atomi Y. Treatment of acute cholangitis due to choledocholithiasis in elderly and younger patients. Arch Surg. 1997;132(10):1129-1133.
81.	Mukai S, Itoi T, Baron TH, et al. Indications and techniques of biliary drainage for acute cholangitis in updated Tokyo Guidelines 2018. [Review]. J Hepatobiliary Pancreat Sci. 24(10):537-549, 2017 Oct.
82.	Andriulli A, Loperfido S, Napolitano G, et al. Incidence rates of post-ERCP complications: a systematic survey of prospective studies. Am J Gastroenterol. 2007;102(8):1781-1788.
83.	Cotton PB, Garrow DA, Gallagher J, Romagnuolo J. Risk factors for complications after ERCP: a multivariate analysis of 11,497 procedures over 12 years. Gastrointest Endosc 2009;70:80-8.
84.	Masci E, Toti G, Mariani A, et al. Complications of diagnostic and therapeutic ERCP: a prospective multicenter study. Am J Gastroenterol 2001;96:417-23.
85.	Kundu R, Pleskow D. Biliary and Pancreatic Stents: Complications and Management. Techniques in Gastrointestinal Endoscopy 2007;9:125-34.
86.	Giovannini M, Moutardier V, Pesenti C, Bories E, Lelong B, Delpero JR. Endoscopic ultrasound-guided bilioduodenal anastomosis: a new technique for biliary drainage. Endoscopy. 2001;33(10):898-900.
87.	Kahaleh M, Artifon EL, Perez-Miranda M, et al. Endoscopic ultrasonography guided biliary drainage: summary of consortium meeting, May 7th, 2011, Chicago. World J Gastroenterol. 2013;19(9):1372-1379.
88.	Minaga K, Kitano M, Imai H, et al. Urgent endoscopic ultrasound-guided choledochoduodenostomy for acute obstructive suppurative cholangitis-induced sepsis. World J Gastroenterol. 2016;22(16):4264-4269.
89.	Kato H, Tsutsumi K, Kawamoto H, Okada H. Current status of endoscopic biliary drainage for unresectable malignant hilar biliary strictures. World J Gastrointest Endosc. 2015;7(11):1032-1038.
90.	Nam HS, Kang DH. Current Status of Biliary Metal Stents. Clin Endosc. 2016;49(2):124-130.
91.	Pisters PW, Hudec WA, Hess KR, et al. Effect of preoperative biliary decompression on pancreaticoduodenectomy-associated morbidity in 300 consecutive patients. Ann Surg. 2001;234(1):47-55.
92.	Sohn TA, Yeo CJ, Cameron JL, Pitt HA, Lillemoe KD. Do preoperative biliary stents increase postpancreaticoduodenectomy complications? J Gastrointest Surg. 2000;4(3):258-267; discussion 267-258.
93.	Lygidakis NJ, van der Heyde MN, Lubbers MJ. Evaluation of preoperative biliary drainage in the surgical management of pancreatic head carcinoma. Acta Chir Scand. 1987;153(11-12):665-668.
94.	Povoski SP, Karpeh MS, Jr., Conlon KC, Blumgart LH, Brennan MF. Association of preoperative biliary drainage with postoperative outcome following pancreaticoduodenectomy. Ann Surg. 1999;230(2):131-142.
95.	Mangiavillano B, Pagano N, Baron TH, Luigiano C. Outcome of stenting in biliary and pancreatic benign and malignant diseases: A comprehensive review. [Review]. World Journal of Gastroenterology. 21(30):9038-54, 2015 Aug 14.World J Gastroenterol. 21(30):9038-54, 2015 Aug 14.
96.	Mukai T, Yasuda I, Nakashima M, et al. Metallic stents are more efficacious than plastic stents in unresectable malignant hilar biliary strictures: a randomized controlled trial. J Hepatobiliary Pancreat Sci. 2013;20(2):214-222.
97.	Lawrence C, Howell DA, Conklin DE, Stefan AM, Martin RF. Delayed pancreaticoduodenectomy for cancer patients with prior ERCP-placed, nonforeshortening, self-expanding metal stents: a positive outcome. Gastrointest Endosc. 2006;63(6):804-807.
98.	Krokidis M, Fanelli F, Orgera G, et al. Percutaneous palliation of pancreatic head cancer: randomized comparison of ePTFE/FEP-covered versus uncovered nitinol biliary stents. Cardiovasc Intervent Radiol 2011;34:352-61.
99.	Kullman E, Frozanpor F, Soderlund C, et al. Covered versus uncovered self-expandable nitinol stents in the palliative treatment of malignant distal biliary obstruction: results from a randomized, multicenter study. Gastrointest Endosc 2010;72:915-23.
100.	Ginsberg G, Cope C, Shah J, et al. In vivo evaluation of a new bioabsorbable self-expanding biliary stent. Gastrointest Endosc. 2003;58(5):777-784.
101.	Hatzidakis A, Krokidis M, Kalbakis K, Romanos J, Petrakis I, Gourtsoyiannis N. ePTFE/FEP-covered metallic stents for palliation of malignant biliary disease: can tumor ingrowth be prevented? Cardiovasc Intervent Radiol. 2007;30(5):950-958.
102.	Schoder M, Rossi P, Uflacker R, et al. Malignant biliary obstruction: treatment with ePTFE-FEP- covered endoprostheses initial technical and clinical experiences in a multicenter trial. Radiology. 2002;225(1):35-42.
103.	Suk KT, Kim JW, Kim HS, et al. Human application of a metallic stent covered with a paclitaxel-incorporated membrane for malignant biliary obstruction: multicenter pilot study. Gastrointest Endosc. 2007;66(4):798-803.
104.	Park DH, Jang JW, Lee SS, Seo DW, Lee SK, Kim MH. EUS-guided biliary drainage with transluminal stenting after failed ERCP: predictors of adverse events and long-term results. Gastrointest Endosc. 2011;74(6):1276-1284.
105.	Park DH, Jeong SU, Lee BU, et al. Prospective evaluation of a treatment algorithm with enhanced guidewire manipulation protocol for EUS-guided biliary drainage after failed ERCP (with video). Gastrointest Endosc. 2013;78(1):91-101.
106.	Vila JJ, Perez-Miranda M, Vazquez-Sequeiros E, et al. Initial experience with EUS-guided cholangiopancreatography for biliary and pancreatic duct drainage: a Spanish national survey. Gastrointest Endosc. 2012;76(6):1133-1141.
107.	Artifon EL, Aparicio D, Paione JB, et al. Biliary drainage in patients with unresectable, malignant obstruction where ERCP fails: endoscopic ultrasonography-guided choledochoduodenostomy versus percutaneous drainage. J Clin Gastroenterol. 2012;46(9):768-774.
108.	Shah JN, Marson F, Weilert F, et al. Single-operator, single-session EUS-guided anterograde cholangiopancreatography in failed ERCP or inaccessible papilla. Gastrointest Endosc. 2012;75(1):56-64.
109.	Leng JJ, Zhang N, Dong JH. Percutaneous transhepatic and endoscopic biliary drainage for malignant biliary tract obstruction: a meta-analysis. World J Surg Oncol. 2014;12(1):272.
110.	Briggs CD, Irving GR, Cresswell A, et al. Percutaneous transhepatic insertion of self-expanding short metal stents for biliary obstruction before resection of pancreatic or duodenal malignancy proves to be safe and effective. Surg Endosc. 2010;24(3):567-571.
111.	Mahgerefteh S, Hubert A, Klimov A, Bloom AI. Clinical Impact of Percutaneous Transhepatic Insertion of Metal Biliary Endoprostheses for Palliation of Jaundice and Facilitation of Chemotherapy. Am J Clin Oncol. 2015;38(5):489-494.
112.	Pinol V, Castells A, Bordas JM, et al. Percutaneous self-expanding metal stents versus endoscopic polyethylene endoprostheses for treating malignant biliary obstruction: randomized clinical trial. Radiology. 2002;225(1):27-34.
113.	Distler M, Kersting S, Ruckert F, et al. Palliative treatment of obstructive jaundice in patients with carcinoma of the pancreatic head or distal biliary tree. Endoscopic stent placement vs. hepaticojejunostomy. JOP. 2010;11(6):568-574.
114.	Smigielski J, Holynski J, Kococik M, et al. [Paliative procedures in cholangiocarcinomas--experience of 5 centers]. Pol Merkur Lekarski. 2009;26(155):416-419.
115.	Alves de Lima SL, Bustamante FAC, Houmeaux de Moura EG, et al. Endoscopic palliative treatment versus surgical bypass in malignant low bile duct obstruction: A systematic review and meta-analysis. Int J Hepatobiliary Pancreat Dis. 2015;5:35-45.
116.	House MG, Cameron JL, Schulick RD, et al. Incidence and outcome of biliary strictures after pancreaticoduodenectomy. Ann Surg 2006;243:571-6; discussion 76-8.
117.	Seyama Y, Makuuchi M. Current surgical treatment for bile duct cancer. World J Gastroenterol. 2007;13(10):1505-1515.
118.	Silva MA, Tekin K, Aytekin F, Bramhall SR, Buckels JA, Mirza DF. Surgery for hilar cholangiocarcinoma; a 10 year experience of a tertiary referral centre in the UK. Eur J Surg Oncol. 2005;31(5):533-539.
119.	Kloek JJ, van der Gaag NA, Aziz Y, et al. Endoscopic and percutaneous preoperative biliary drainage in patients with suspected hilar cholangiocarcinoma. J Gastrointest Surg. 2010;14(1):119-125.
120.	Saluja SS, Gulati M, Garg PK, et al. Endoscopic or percutaneous biliary drainage for gallbladder cancer: a randomized trial and quality of life assessment. Clin Gastroenterol Hepatol. 2008;6(8):944-950 e943.
121.	Paik WH, Park YS, Hwang JH, et al. Palliative treatment with self-expandable metallic stents in patients with advanced type III or IV hilar cholangiocarcinoma: a percutaneous versus endoscopic approach. Gastrointest Endosc. 2009;69(1):55-62.
122.	Mansfield SD, Barakat O, Charnley RM, et al. Management of hilar cholangiocarcinoma in the North of England: pathology, treatment, and outcome. World J Gastroenterol. 2005;11(48):7625-7630.
123.	Fabbri C, Luigiano C, Lisotti A, et al. Endoscopic ultrasound-guided treatments: are we getting evidence based--a systematic review. World J Gastroenterol. 2014;20(26):8424-8448.
124.	Ogura T, Sano T, Onda S, et al. Endoscopic ultrasound-guided biliary drainage for right hepatic bile duct obstruction: novel technical tips. Endoscopy. 2015;47(1):72-75.
125.	Park SJ, Choi JH, Park DH, et al. Expanding indication: EUS-guided hepaticoduodenostomy for isolated right intrahepatic duct obstruction (with video). Gastrointest Endosc. 2013;78(2):374-380.
126.	Prachayakul V, Aswakul P. Endoscopic ultrasound-guided biliary drainage: Bilateral systems drainage via left duct approach. World J Gastroenterol. 2015;21(34):10045-10048.
127.	Papadopoulos V, Filippou D, Manolis E, Mimidis K. Haemostasis impairment in patients with obstructive jaundice. J Gastrointestin Liver Dis. 2007;16(2):177-186.
128.	Ferreira LE, Baron TH. Post-sphincterotomy bleeding: who, what, when, and how. Am J Gastroenterol. 2007;102(12):2850-2858.
129.	Saad WE, Wallace MJ, Wojak JC, Kundu S, Cardella JF. Quality improvement guidelines for percutaneous transhepatic cholangiography, biliary drainage, and percutaneous cholecystostomy. J Vasc Interv Radiol. 2010;21(6):789-795.
130.	Tsauo J, Li X, Li H, et al. Transjugular insertion of bare-metal biliary stent for the treatment of distal malignant obstructive jaundice complicated by coagulopathy. Cardiovasc Intervent Radiol. 2013;36(2):521-525.
131.	Ring EJ, Kerlan RK, Jr. Interventional biliary radiology. AJR Am J Roentgenol. 1984;142(1):31-34.
132.	Seif HM, Zidan M, Helmy A. One-stage percutaneous triple procedure for treatment of endoscopically unmanageable patients with malignant biliary obstruction and marked ascites. Arab J Gastroenterol. 2013;14(4):148-153.
133.	Sofue K, Arai Y, Takeuchi Y, Fujiwara H, Tokue H, Sugimura K. Safety and efficacy of primary metallic biliary stent placement with tract embolization in patients with massive ascites: a retrospective analysis of 16 patients. J Vasc Interv Radiol. 2012;23(4):521-527.
134.	Hara K, Yamao K, Mizuno N, et al. Endoscopic ultrasonography-guided biliary drainage: Who, when, which, and how? World J Gastroenterol. 2016;22(3):1297-1303.
135.	Sharaiha RZ, Kumta NA, Desai AP, et al. Endoscopic ultrasound-guided biliary drainage versus percutaneous transhepatic biliary drainage: predictors of successful outcome in patients who fail endoscopic retrograde cholangiopancreatography. Surg Endosc. 2016.

Disclaimer

The ACR Committee on Appropriateness Criteria and its expert panels have developed criteria for determining appropriate imaging examinations for diagnosis and treatment of specified medical condition(s). These criteria are intended to guide radiologists, radiation oncologists and referring physicians in making decisions regarding radiologic imaging and treatment. Generally, the complexity and severity of a patient’s clinical condition should dictate the selection of appropriate imaging procedures or treatments. Only those examinations generally used for evaluation of the patient’s condition are ranked. Other imaging studies necessary to evaluate other co-existent diseases or other medical consequences of this condition are not considered in this document. The availability of equipment or personnel may influence the selection of appropriate imaging procedures or treatments. Imaging techniques classified as investigational by the FDA have not been considered in developing these criteria; however, study of new equipment and applications should be encouraged. The ultimate decision regarding the appropriateness of any specific radiologic examination or treatment must be made by the referring physician and radiologist in light of all the circumstances presented in an individual examination.