Early Diagnosis And Management Of Malignant Distal Biliary Obstruction: A Review On Current Recommendations And Guidelines

Abstract

Malignant biliary obstruction is a challenging condition, requiring a multimodal approach for both diagnosis and treatment. Pancreatic adenocarcinoma and cholangiocarcinoma are the leading causes of malignant distal biliary obstruction. Early diagnosis is difficult to establish as biliary obstruction can be the first presentation of the underlying disease, which can already be at an advanced stage. Consequently, the majority of patients (70%) with malignant distal biliary obstruction are unresectable at the time of diagnosis. The association of clinical findings, laboratory tests, imaging, and endoscopic modalities may help in identifying the underlying cause. Novel endoscopic techniques such as cholangioscopy, intraductal ultrasonography, or confocal laser endomicroscopy have been developed with promising results, but are not used in routine clinical practice. As the number of patients with malignant distal biliary obstruction who will undergo curative surgery is limited, endoscopy has a crucial role in palliation, to relieve biliary obstruction. According to the last European guidelines published in the management of biliary obstruction, self-expandable metal stents have a central place in biliary drainage compared to plastic stents. Endoscopic ultrasound has evolved impressively in the last decades. When standard techniques of biliary cannulation by endoscopic retrograde cholangiopancreatography fail, endoscopic ultrasound-guided biliary drainage is a good option compared to percutaneous drainage.

Keywords: distal biliary stricture; palliative biliary drainage; pancreaticobiliary malignancy; preoperative biliary drainage; self-expandable metal stent.

Figure 1

A 69-year-old presented with abdominal pain and cholestasis. MRI showed a double duct sign and a suspected lesion at the papillary area (A), presenting an abnormal diffusion-weighted signal and suggestive of an ampulloma (B). ERCP revealed an ampullary mass (C) and standard biopsies were performed confirming the diagnosis of ampullary carcinoma. A 10mm USEMS of 6 cm of length is placed to relieve the obstruction (D, E). Abbreviations: MRI, Magnetic resonance imaging; ERCP, Endoscopic retrograde cholangiopancreatography; USEMS, uncovered self-expandable metal stents.

Figure 2

A 67-year-old woman presenting with dyspepsia, weight loss and jaundice. CT showed a 6 cm mass in the head of the pancreas with vascular involvement (SMV > 270°, SMA >120%) compressing the distal CBD (A). Both EUS-FNB and ERCP with brushings confirmed non-resectable pancreatic adenocarcinoma (B). A 10mm USEMS 4cm was inserted to provide drainage before neoadjuvant chemotherapy (C). Abbreviations: SMV, superior mesenteric vein; SMA, superior mesenteric artery; CBD, common bile duct; EUS-FNB, endoscopic ultrasound fine needle biopsy; ERCP, Endoscopic retrograde cholangiopancreatography; USEMS, uncovered self-expandable metal stent.

Figure 3

A 84-year-old woman presenting painless jaundice. TUS showed CBD and intrahepatic bile duct dilatation. MRI showed a suspected 22mm intraductal mass at the distal part of the CBD with an upstream dilatation (A). EUS-FNA confirmed an intraductal mass in the CBD suggestive of cholangiocarcinoma. ERCP revealed a long, irregular, distal biliary stricture (B); brushing and intraductal forceps biopsies confirmed the presence of malignant cells (C). Abbreviations: TUS, transabdominal ultrasound; CBD, common bile duct; MRI, Magnetic resonance imaging; EUS-FNA, endoscopic ultrasound fine needle biopsy; ERCP, Endoscopic retrograde cholangiopancreatography.

Figure 4

Algorithm for the assessment of patients with biliary obstruction. Abbreviations: TUS, transabdominal ultrasonography; CT, computed tomography; MRI, Magnetic resonance imaging; MDBO, malignant distal biliary obstruction; EUS, endoscopic ultrasound; FNA, fine needle aspiration; CCA, cholangiocarcinoma; PSC, primary sclerosing cholangitis; SOC, single-operator-cholangioscopy; IDUS, intraductal ultrasonography; CLE, confocal laser endomicroscopy; CA 19–9, Carbohydrate antigen 19–9.

Figure 5

Algorithm for the endoscopic management of patients with confirmed pancreaticobiliary malignancy. Abbreviations: ERCP, Endoscopic retrograde cholangiopancreatography; SEMS, self-expandable metal stents; PTC, percutaneous cholangiography; EUS, endoscopic ultrasound.