Current endoscopic approach to indeterminate biliary strictures

Abstract

Biliary strictures are considered indeterminate when basic work-up, including transabdominal imaging and endoscopic retrograde cholangiopancreatography with routine cytologic brushing, are non-diagnostic. Indeterminate biliary strictures can easily be mischaracterized which may dramatically affect patient's outcome. Early and accurate diagnosis of malignancy impacts not only a patient's candidacy for surgery, but also potential timely targeted chemotherapies. A significant portion of patients with indeterminate biliary strictures have benign disease and accurate diagnosis is, thus, paramount to avoid unnecessary surgery. Current sampling strategies have suboptimal accuracy for the diagnosis of malignancy. Emerging data on other diagnostic modalities, such as ancillary cytology techniques, single operator cholangioscopy, and endoscopic ultrasonography-guided fine needle aspiration, revealed promising results with much improved sensitivity.

Keywords: Bile duct; Bile duct stricture; Cholangiocarcinoma; Cholangioscopy; Confocal microscopy; Endoscopic retrograde cholangiopancreatography; Endoscopic ultrasound; Indeterminate biliary stricture; Indeterminate stricture; Primary sclerosing cholangitis; Single operator cholangioscope; Spyglass; Transpapillary biopsy.

Figure 1

Fluoroscopic image during endoscopic retrograde cholangiopancreatography showing a hilar stricture with left intrahepatic biliary dilation. Endoscopic brushing was performed and routine cytology confirmed hilar cholangiocarcinoma.

Figure 2

Intraductal ultrasound showing bile duct mass and surrounding lymph nodes.

Figure 3

Endoscopic diagnosis and therapy for a bile duct mass missed on transabdominal imaging. A: Endoscopic ultrasound showing a bile duct mass that was missed by computed tomography and magnetic resonance imaging; B: Biliary dilation was present proximal to the stenosis; C: Endoscopic ultrasound-guided fine needle aspiration was performed and was diagnostic of cholangiocarcinoma; D: Endoscopic retrograde cholangioscopy was performed during the same session and cholangiography revealed distal biliary stricture; E, F: A fully-covered metal biliary stent was placed.

Figure 4

Endoscopic ultrasound evaluation of bile duct mass not seen on transabdominal imaging. A: Endoscopic ultrasound demonstrating the presence of bile duct mass; B: Endoscopic ultrasound-guided fine needle aspiration was diagnostic of cholangiocarcinoma

Figure 5

The “mother-baby” scope cholangioscopy system. The main disadvantage of this system is the requirement for two endoscopists to perform the procedure.

Figure 6

Spyglass single operator cholangioscopy system. A: SpyScope 10Fr access and delivery catheter; B: SpyGlass fiber optic probe; C: SpyBite biopsy forceps.

Figure 7

Single operator cholangioscopy used to obtain a diagnosis in a stricture with nondiagnostic cytology. A: Magnetic resonance cholangiopancreatography showing a long distal biliary stricture with proximal biliary dilation. Endoscopic retrograde cholangiopancreatography with brushing was non-diagnostic; B: SpyGlass cholangioscopy revealed a malignant-appearing ulcerated biliary stricture. Spybite biopsies confirmed cholangiocarcinoma.

Figure 8

SpyGlass cholangioscopy revealing a bile duct mass. This is indicative of cholangiocarcinoma.