Background: Portal biliopathy is the presence of functional or structural biliary changes due to porto-systemic collaterals in portal hypertension (especially in extra hepatic portal vein obstruction - EHPVO). A preliminary portosystemic shunt is usually recommended before attempts at biliary decompression or bypass in symptomatic patients.Aim: To review our experience in the surgical management of symptomatic portal biliopathy.
Methods: From a prospectively maintained computerised database, 93 patients presenting with EHPVO were evaluated over the last 8 years. Surgery was required in 23 patients. Seven of these patients had features of portal biliopathy, and form the basis of this review.
Results: Presenting features were jaundice in 5 (cholangitis in 4); Gastrointestinal bleeding in 3 and symptomatic hypersplenism in one. One of the jaundiced patients had been referred as hilar cholangiocarcinoma. Commonest structural change observed was combined involvement of extrahepatic and bilateral intrahepatic biliary system (Type III b, n=5). Five patients had Common bile duct calculi and 2 had gallstones. Three patients underwent portosystemic shunting (splenorenal in 2 and mesocaval in 1). Four patients had hepaticojejunostomy - one with bile duct resection (for presumed malignancy) and 3 without manifest GI bleed and operative appearance of mild portal hypertension, although they were kept prepared for a shunt (should it have been required). One patient each after shunt and bypass respectively, developed recurrent cholangitis but resolved on conservative management. The patient with bile duct resection had subsequent ectopic variceal bleed and required a splenorenal shunt. Follow-up serum bilirubin reduced faster (Range 4-57 weeks) than alkaline phosphatase levels (Range 4- 208 weeks).
Conclusions: Portal biliopathy must be considered in evaluation of biliary complications in EHPVO. Jaundice is the commonest presentation, and Type III b is the most frequently encountered anatomical anomaly. Surgery can relieve most symptomatic patients. Shunt surgery (usually splenorenal) may be adequate in some patients to decompress the biliary obstruction. Direct hepaticojejunostomy is possible in selected patients without severe portal Hypertension.