Novel Non-Surgical Interventions for Benign Inflammatory Biliary Strictures in Infants: A Report of Two Cases and Review of Current Pediatric Literature

Benign idiopathic biliary strictures are exceedingly rare in infants [1, 2]. Patients may present with similar signs and symptoms as other causes of hepatobiliary disease. Clinicians must maintain a high index of suspicion to avoid misdiagnosis. Historically, these cases were managed surgically [1, 2], however less invasive treatments utilizing interventional radiology and endoscopic techniques are becoming more common, with similar outcomes and improved safety profiles [3]. Here, we present a report of two infants with benign inflammatory biliary strictures that were successfully managed with a minimally invasive approach and a review of all pediatric cases of idiopathic biliary strictures in current literature.

Benign inflammatory biliary strictures should be considered in the differential diagnosis of an infant with cholestasis and elevated GGT. Although the stricture may not be visible on ultrasound, intrahepatic biliary dilatation may be seen and is suggestive of an obstructive process. Cross-sectional imaging, such as CT or MRI/MRCP may be helpful in identifying the strictured segment. Finally, a percutaneous or endoscopic cholangiogram can be both diagnostic and therapeutic.

Benign inflammatory biliary strictures have been described in the literature on several occasions in patients older than 1 year at time of presentation and in one infant 3 months of age (Table 1) [1, 2, 5, 6].

Table 1
Prior reported cases of benign biliary strictures

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In 1989, Standfield et al. [5] reviewed 12 cases of benign non-traumatic strictures between 1975 and 1986 in patients aged 1.5 to 60 years old. Four of these were pediatric patients aged 1.5 years old, 6 years old, 13 years old and 15 years old. All patients underwent laparotomy. Three of the four pediatric patients had excision with Roux-en-Y reconstruction. The fourth pediatric patient was initially treated with a T-tube, and subsequently a hepaticojejunostomy. Extrahepatic bile duct biopsies were reviewed from all 12 cases and included histologic features of chronic inflammation with lymphocytic and plasma cell infiltrates, ulceration, fibrosis and granulation tissue and changes in bile duct epithelium.

Bowles et al. [1] reports on 7 pediatric patients with benign strictures who underwent successful surgical intervention with biliary-enteric anastomosis. Five patients initially presented with obstructive jaundice, 1 with nonspecific gastrointestinal symptoms, and 1 with pruritus and bruising. Described patients were ages 2.5 years old to 15 years old. Five of these patients underwent resection of the stricture requiring hepaticojejunostomy. One 14 year old patient did have initial stent placement at the porta hepatis without resection, however, she required hepaticojejunostomy 2 years later. Again, denudation of biliary epithelium was observed in all but one lesion. Fibrosis and or signs of chronic inflammation were found in all biopsies and granulation tissue confirmed in 1 biopsy. Biopsy results were not available for review in one patient [1].

In a report of unusual cases of extrahepatic biliary obstruction, Krishna et al. [2] described 136 cases. Three of these were identified as idiopathic benign non-traumatic inflammatory strictures. The patients were ages 15 months, 3 years old and 13 years old. A Roux-en-Y hepaticojejunostomy was performed in all 3 of these cases, with excision of the stricture in the 3 year old and 13 year old. The 15 month old patient required hepaticojejunostomy alone. The 13 year old patient also had hepaticolithiasis at the time of presentation. Histopathology was consistent with prior descriptions of inflammatory biliary stricture with ulcerated biliary epithelium, fibrosis and signs of chronic inflammation [2].

During review of literature, one case of a benign inflammatory stricture in a patient less than 1 year at time of presentation was identified [6]. A 3 month old male presented with new onset diarrhea, progressively pale stools, weight loss and jaundice. Cholangiography confirmed a dilated CBD with sudden narrowing in the distal segment, but no signs of cysts or other extrinsic compression. This patient underwent duodenotomy with transpapillary dilatation of the stenotic segment. However, he later required cholecystectomy with T tube placement via the cystic duct remnant to stent the dilated segment. The stent was removed after 1 month and the patient remained well at 9 month follow-up.

In summary, there are few reports cases of inflammatory biliary strictures in children, with only one reported case in an infant less than one year. Furthermore, all reported cases have been managed surgically. The advantages of less invasive intervention in non-traumatic strictures have been described extensively in the literature with respect to adult patients [3], however, there is a paucity of literature discussing non-surgical outcomes with this disease entity in infants less than one year of age. We make this important age distinction to emphasize the benefits of the option of noninvasive procedures in this fragile age group.

A rendezvous technique describes access to an impervious location by way of two separate entry points. This approach for hepatobiliary dysfunction at the site of surgical anastomosis has been described with success in the pediatric transplant population and in infants with previous surgical intervention [7]. To our knowledge, it has not been described in patients with benign inflammatory strictures.

While we emphasize the benefits of the option of noninvasive procedures in this delicate age group, intervention in this cohort is not without its risks. Small ducts are difficult to cannulate and successful access requires procedural experience and expertise that many providers struggle to achieve with only a few number of cases at even large centers each year. The procedure itself requires specialized equipment including a side-view neonatal endoscope for ERCP that is expensive and not widely produced. Finally, biliary drainage tubes used by interventional radiology are not produced in diameters small enough to cannulate infant bile ducts requiring interventionalists to fashion their own tubes by cutting holes in catheters for ‘off label’ use. Still, in our experience the advantages of minimal post-procedural pain, infection risk, bleeding risk and ultimately hospitalization render the noninvasive treatment approach superior.

Benign inflammatory biliary strictures in infants may present similarly to other causes of obstructive cholestasis including biliary atresia and extrinsic compression. A high index of suspicion and early distinction may prevent unnecessary surgical procedures. Furthermore, we describe percutaneous access to the biliary tree with or without combined endoscopy, as a feasible approach for infants with benign inflammatory strictures. Less invasive percutaneous and endoscopic interventions may be utilized to treat these patients with excellent outcomes.