American College of Radiology
ACR Appropriateness Criteria®

Radiologic Management of Benign and Malignant Biliary Obstruction

Variant 1: Initial therapeutic procedure for a patient with dilated bile ducts from benign biliary obstruction (eg, choledocholithiasis).
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Endoscopic internal biliary catheter Usually appropriate N/A N/A 8 n/a 0 0 0 0 0 0 0 0 0
Percutaneous internal/external biliary catheter May be appropriate N/A N/A 6 n/a 0 0 0 0 0 0 0 0 0
Surgery (transplant or hepaticojejunostomy) Usually not appropriate N/A N/A 2 n/a 0 0 0 0 0 0 0 0 0
Medical management only Usually not appropriate N/A N/A 2 n/a 0 0 0 0 0 0 0 0 0
Permanent biliary metallic stent Usually not appropriate N/A N/A 1 n/a 0 0 0 0 0 0 0 0 0
Removable biliary covered stent May be appropriate N/A N/A 4 n/a 0 0 0 0 0 0 0 0 0
Endosonography-guided biliary drainage (ESBD) May be appropriate N/A N/A 4 n/a 0 0 0 0 0 0 0 0 0
Variant 2: Initial therapeutic procedure for a patient with elevated bilirubin and suspected sclerosing cholangitis.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Endoscopic internal biliary catheter Usually appropriate N/A N/A 8 n/a 0 0 0 0 0 0 0 0 0
Percutaneous internal/external biliary catheter May be appropriate N/A N/A 6 n/a 0 0 0 0 0 0 0 0 0
Surgery (transplant or hepaticojejunostomy) Usually not appropriate N/A N/A 2 n/a 0 0 0 0 0 0 0 0 0
Medical management only May be appropriate N/A N/A 6 n/a 0 0 0 0 0 0 0 0 0
Permanent biliary metallic stent Usually not appropriate N/A N/A 1 n/a 0 0 0 0 0 0 0 0 0
Removable biliary covered stent Usually not appropriate N/A N/A 2 n/a 0 0 0 0 0 0 0 0 0
Variant 3: Initial therapeutic procedure for a patient with malignant common bile duct obstruction (eg, pancreatic carcinoma).
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Endoscopic internal biliary catheter Usually appropriate N/A N/A 8 n/a 0 0 0 0 0 0 0 0 0
Percutaneous internal/external biliary catheter Usually appropriate N/A N/A 7 n/a 0 0 0 0 0 0 0 0 0
Surgery (transplant or hepaticojejunostomy) May be appropriate N/A N/A 5 n/a 0 0 0 0 0 0 0 0 0
Medical management only Usually not appropriate N/A N/A 3 n/a 0 0 0 0 0 0 0 0 0
Percutaneous biliary metallic stent May be appropriate N/A N/A 5 n/a 0 0 0 0 0 0 0 0 0
Removable biliary covered stent May be appropriate N/A N/A 5 n/a 0 0 0 0 0 0 0 0 0
Endosonography-guided biliary drainage (ESBD) May be appropriate N/A N/A 4 n/a 0 0 0 0 0 0 0 0 0
Variant 4: Initial therapeutic procedure for a patient with hilar biliary obstruction from malignant etiology (eg, Klatskin tumor).
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Endoscopic internal biliary catheter May be appropriate N/A N/A 6 n/a 0 0 0 0 0 0 0 0 0
Percutaneous internal/external biliary catheter Usually appropriate N/A N/A 8 n/a 0 0 0 0 0 0 0 0 0
Surgery (transplant or hepaticojejunostomy) May be appropriate N/A N/A 5 n/a 0 0 0 0 0 0 0 0 0
Medical management only Usually not appropriate N/A N/A 2 n/a 0 0 0 0 0 0 0 0 0
Permanent biliary metallic stent May be appropriate N/A N/A 6 n/a 0 0 0 0 0 0 0 0 0
Removable biliary covered stent May be appropriate N/A N/A 5 n/a 0 0 0 0 0 0 0 0 0
Endosonography-guided biliary drainage (ESBD) Usually not appropriate N/A N/A 3 n/a 0 0 0 0 0 0 0 0 0
Variant 5: Initial therapeutic procedure for a patient with elevated bilirubin and dilated bile ducts from unknown etiology.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Endoscopic internal biliary catheter Usually appropriate N/A N/A 8 n/a 0 0 0 0 0 0 0 0 0
Percutaneous internal/external biliary catheter Usually appropriate N/A N/A 7 n/a 0 0 0 0 0 0 0 0 0
Surgery (transplant or hepaticojejunostomy) Usually not appropriate N/A N/A 2 n/a 0 0 0 0 0 0 0 0 0
Medical management only Usually not appropriate N/A N/A 2 n/a 0 0 0 0 0 0 0 0 0
Permanent biliary metallic stent Usually not appropriate N/A N/A 1 n/a 0 0 0 0 0 0 0 0 0
Removable biliary covered stent Usually not appropriate N/A N/A 3 n/a 0 0 0 0 0 0 0 0 0
Endosonography-guided biliary drainage (ESBD) Usually not appropriate N/A N/A 3 n/a 0 0 0 0 0 0 0 0 0
Variant 6: Initial therapeutic procedure for a patient with dilated bile ducts and coagulopathy (INR >2.0 and/or platelet count <60 K).
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Endoscopic internal biliary catheter Usually appropriate N/A N/A 8 n/a 0 0 0 0 0 0 0 0 0
Percutaneous internal/external biliary catheter May be appropriate N/A N/A 6 n/a 0 0 0 0 0 0 0 0 0
Surgery (transplant or hepaticojejunostomy) Usually not appropriate N/A N/A 2 n/a 0 0 0 0 0 0 0 0 0
Medical management only May be appropriate N/A N/A 4 n/a 0 0 0 0 0 0 0 0 0
Permanent biliary metallic stent Usually not appropriate N/A N/A 1 n/a 0 0 0 0 0 0 0 0 0
Removable biliary covered stent Usually not appropriate N/A N/A 2 n/a 0 0 0 0 0 0 0 0 0
Endosonography-guided biliary drainage (ESBD) Usually not appropriate N/A N/A 3 n/a 0 0 0 0 0 0 0 0 0
Variant 7: Initial therapeutic procedure for a patient with dilated bile ducts and moderate to massive ascites.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Endoscopic internal biliary catheter Usually appropriate N/A N/A 8 n/a 0 0 0 0 0 0 0 0 0
Percutaneous internal/external biliary catheter May be appropriate N/A N/A 5 n/a 0 0 0 0 0 0 0 0 0
Surgery (transplant or hepaticojejunostomy) Usually not appropriate N/A N/A 2 n/a 0 0 0 0 0 0 0 0 0
Medical management only May be appropriate N/A N/A 4 n/a 0 0 0 0 0 0 0 0 0
Permanent biliary metallic stent Usually not appropriate N/A N/A 2 n/a 0 0 0 0 0 0 0 0 0
Removable biliary covered stent May be appropriate N/A N/A 4 n/a 0 0 0 0 0 0 0 0 0
Endosonography-guided biliary drainage (ESBD) Usually not appropriate N/A N/A 3 n/a 0 0 0 0 0 0 0 0 0
Variant 8: Initial therapeutic procedure for a patient with dilated bile ducts and suspected biliary sepsis/acute cholangitis.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Endoscopic internal biliary catheter Usually appropriate N/A N/A 8 n/a 0 0 0 0 0 0 0 0 0
Percutaneous internal/external biliary catheter Usually appropriate N/A N/A 8 n/a 0 0 0 0 0 0 0 0 0
Surgery (transplant or hepaticojejunostomy) Usually not appropriate N/A N/A 2 n/a 0 0 0 0 0 0 0 0 0
Medical management only Usually not appropriate N/A N/A 2 n/a 0 0 0 0 0 0 0 0 0
Permanent biliary metallic stent Usually not appropriate N/A N/A 1 n/a 0 0 0 0 0 0 0 0 0
Removable biliary covered stent Usually not appropriate N/A N/A 2 n/a 0 0 0 0 0 0 0 0 0
Endosonography-guided biliary drainage (ESBD) May be appropriate N/A N/A 4 n/a 0 0 0 0 0 0 0 0 0
Variant 9: Initial therapeutic procedure for a liver transplant recipient with elevated bilirubin and suspected biliary anastomotic stenosis and/or bile leak, with no dilated ducts.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Endoscopic internal biliary catheter Usually appropriate N/A N/A 8 n/a 0 0 0 0 0 0 0 0 0
Percutaneous internal/external biliary catheter Usually appropriate N/A N/A 8 n/a 0 0 0 0 0 0 0 0 0
Surgery (transplant or hepaticojejunostomy) Usually not appropriate N/A N/A 3 n/a 0 0 0 0 0 0 0 0 0
Medical management only Usually not appropriate N/A N/A 2 n/a 0 0 0 0 0 0 0 0 0
Permanent biliary metallic stent Usually not appropriate N/A N/A 1 n/a 0 0 0 0 0 0 0 0 0
Removable biliary covered stent May be appropriate N/A N/A 5 n/a 0 0 0 0 0 0 0 0 0
Endosonography-guided biliary drainage (ESBD) Usually not appropriate N/A N/A 3 n/a 0 0 0 0 0 0 0 0 0
Variant 10: Initial therapeutic procedure for a patient with bile leak and dilated bile ducts following laparoscopic cholecystectomy.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Endoscopic internal biliary catheter Usually appropriate N/A N/A 8 n/a 0 0 0 0 0 0 0 0 0
Percutaneous internal/external biliary catheter Usually appropriate N/A N/A 8 n/a 0 0 0 0 0 0 0 0 0
Surgery (transplant or hepaticojejunostomy) May be appropriate N/A N/A 4 n/a 0 0 0 0 0 0 0 0 0
Medical management only Usually not appropriate N/A N/A 1 n/a 0 0 0 0 0 0 0 0 0
Permanent biliary metallic stent Usually not appropriate N/A N/A 1 n/a 0 0 0 0 0 0 0 0 0
Removable biliary covered stent Usually not appropriate N/A N/A 1 n/a 0 0 0 0 0 0 0 0 0
Endosonography-guided biliary drainage (ESBD) Usually not appropriate N/A N/A 1 n/a 0 0 0 0 0 0 0 0 0
Please refer to the supporting documentation for a more complete discussion of the concepts and their definitions below.
Final Tabulations:
A histogram of the number of panel members who rated the recommendation as noted in the column heading (ie, 1, 2, 3, …etc.)
Disagree:
The variation of the individual ratings from the median rating indicates panel disagreement on the final recommendation.
References:
Lists the references associated with the recommendation
SQ:
Study Quality (1, 2, 3, 4, Good M or Inadequate M) of the references listed.
RRL:
Information on the Relative Radiation Level (RRL) designations can be found here.