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Review
. 2025 Jan 30;15(3):325.
doi: 10.3390/diagnostics15030325.

Diagnostic Approach to Biliary Strictures

Daniyal Raza  1 , Sahib Singh  2 , Stefano Francesco Crinò  3 , Ivo Boskoski  4 , Cristiano Spada  4 , Lorenzo Fuccio  5 , Jayanta Samanta  6 , Jahnvi Dhar  6 , Marco Spadaccini  7 , Paraskevas Gkolfakis  8 , Marcello Fabio Maida  9 , Jorge Machicado  10 , Marcello Spampinato  11 , Antonio Facciorusso  12
Affiliations
Review

Diagnostic Approach to Biliary Strictures

Daniyal Raza et al. Diagnostics (Basel). .

Abstract

Biliary strictures represent a narrowing of the bile ducts, leading to obstruction that may result from benign or malignant etiologies. Accurate diagnosis is crucial but challenging due to overlapping features between benign and malignant strictures. This review presents a comprehensive diagnostic approach that integrates biochemical markers, imaging modalities, and advanced endoscopic techniques to distinguish between these causes. Imaging tools such as ultrasound, MRI/MRCP, and CECT are commonly used, each with distinct advantages and limitations. Furthermore, endoscopic procedures such as ERCP and EUS are key in tissue acquisition, enhancing diagnostic accuracy, especially for indeterminate or complex strictures. Recent innovations, including artificial intelligence and new endoscopic techniques, hold promise in enhancing precision and reducing diagnostic challenges. This review emphasizes a multidisciplinary strategy to improve diagnostic pathways, ensuring timely management for patients with biliary strictures.

Keywords: CECT; ERCP; EUS; MRI/MRCP; artificial intelligence; biliary strictures; cholangioscopy; tumor markers.

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Conflict of interest statement

The authors declare no conflicts of interest.

Figures

Figure 3
Figure 3
This sequence of images illustrates the procedural steps of intraductal balloon-guided direct peroral cholangioscopy. (A): Placement of a guidewire, with or without a 5-French drainage catheter, into a branch of the intrahepatic duct for securing access. (B): Introduction of an ultraslim endoscope, guided along the wire, to the ampulla of Vater. (C): Insertion and inflation of a 5-French balloon catheter to anchor within the duct, ensuring stability during endoscopic advancement. (D): Advancement of the ultraslim endoscope over the fixed balloon catheter to enable direct visualization of the biliary tract. (E): Radiographic confirmation of the ultraslim endoscope’s placement within the proximal biliary tree, allowing for precise diagnostic and therapeutic maneuvers [76].
Figure 1
Figure 1
EUS-FNB of an extra-hepatic biliary stricture. CBD, common bile duct.
Figure 2
Figure 2
Comparison of sensitivity between EUS-TA and ERCP for diagnosing distal biliary strictures [32].
Figure 4
Figure 4
Flowchart depicting the diagnostic algorithm for biliary strictures. Abbreviations expanded: CBD (Common Bile Duct), LFTs (Liver Function Tests), ALP (Alkaline Phosphatase), CA-19-9 (Cancer Antigen 19-9), CEA (Carcinoembryonic Antigen), MRI (Magnetic Resonance Imaging), MRCP (Magnetic Resonance Cholangiopancreatography), CECT (Contrast Enhanced Computed Tomography), ERCP (Endoscopic Retrograde Cholangiopancreatography), EUS (Endoscopic Ultrasound), IDUS (Intraductal Ultrasound), CLE (Confocal Laser Endomicroscopy).
See this image and copyright information in PMC

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