Large bile duct obstruction
- Lesion
A blocked bile duct backs bile into the liver; bacteria can climb in, and years of blockage scar the liver.
What it is
Obstruction of the extrahepatic or large intrahepatic bile ducts, most often by gallstones, cancer of the pancreatic head or bile ducts, or benign strictures, causes cholestasis with portal changes. Infection of stagnant bile produces ascending cholangitis and liver abscesses. Unrelieved obstruction causes secondary biliary cirrhosis. Sepsis also causes cholestasis without obstruction, and primary hepatolithiasis forms stones inside intrahepatic ducts.
Key facts
- Primary hepatolithiasis: pigment stones in intrahepatic ducts, mostly in East Asia, with recurrent cholangitis, biliary cirrhosis and a raised risk of cholangiocarcinoma.
- Painless jaundice with a palpable gallbladder (Courvoisier sign) suggests malignant obstruction rather than stones.
Structure
- Gross: bile-stained green liver; dilated ducts upstream of the obstruction.
- Micro: portal edema, ductular reaction, neutrophils in duct walls and lumens (cholangitis), bile lakes and bile infarcts.
Step by step
- A stone, tumour or stricture blocks a large bile duct.
- Bile backs up: canalicular bile plugs, rising conjugated bilirubin and alkaline phosphatase.
- Portal tracts swell, ductules proliferate and neutrophils gather.
- Bile leaks and kills groups of hepatocytes (bile infarcts).
- Stagnant bile is colonized by gut bacteria: cholangitis, sometimes abscesses and sepsis.
- Months of obstruction lead to periportal fibrosis and secondary biliary cirrhosis.
Test yourself
Think of the answer, then tap the question to see it.
What is a bile infarct?
A focus of hepatocyte necrosis caused by the toxic effect of extravasated bile, a sign of large duct obstruction.
What is the classic triad of ascending cholangitis?
Fever, jaundice and right upper quadrant pain (Charcot triad).
What does ductular cholestasis at the edge of portal tracts suggest?
Cholestasis of sepsis, which carries a poor prognosis.
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Educational content on the mechanisms of disease; not a diagnostic or treatment guide and no substitute for a health professional's advice. No doses are given.
Sources: Choledocholithiasis (StatPearls (NCBI Bookshelf), 2026); Cholangitis (StatPearls (NCBI Bookshelf), 2023).
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Representative model, for educational purposes only.