Management

The management of a biliary fistula should be considered in 5 sequential stages:

• establish the anatomy of the fistula - for external types, the origin and tract can be delineated by injecting contrast material through the external orifice. For internal varieties, the anatomic extent may be delineated using an upper GI series, barium enema, cholangiography or cystography. ERCP enables visualisation of the distal biliary tree; TCP demonstrates both the intrahepatic biliary system and extrahepatic ductal system.
  
  
• establish cause of fistula - gastroduodenoscopy, sonography and cytologic evaluation of aspirated specimens.
  
  
• control infection - use antibiotics effective against gram-negative bacilli and against anaerobes, e.g. ampicillin. Culture specimens from an external fistula to target more effectively the antibiotic.
  
  
• correct electrolyte imbalance and nutritional deficiency
  
  
• surgical - establish drainage and relieve obstruction, where it exists, by endoscopic papillotomy. Most fistulas can "dry out" but continuing jaundice, sepsis or electrolyte disturbance may force surgery.