Vitale, md, mathew george, md, kelley mcintyre, gerald m. The majority is malignant entities, but some may have benign etiologies. Management of malignant biliary strictures springerlink. Benign biliary strictures are most commonly iatrogenic in nature and are a consequence of hepatobiliary surgery.
Biliary and pancreatic cancers occur silently in the initial stage and become unresectable within a short time. This is a retrospective analysis of 342 patients who underwent euseusfna from 2002 to 2009 after presenting with obstructive jaundice and a biliary stricture. Differential diagnosis of benign and malignant distal biliary. In contrast to malignant biliary obstruction, in which shortterm palliation is often the goal of therapy, benign strictures require durable repair because most patients are in otherwise good health and. Oct 16, 2019 the major determinant of mortality in patients with bile duct strictures is the underlying disease condition. The wallflex biliary rx fully covered stent system rmv is indicated for use in the palliative treatment of biliary strictures produced by malignant neoplasms, relief of malignant biliary obstruction prior to surgery and for indwell up to 12 months in the treatment of benign biliary strictures secondary to chronic pancreatitis. Majority 70%80% of the biliary strictures are malignant. Dr m k chouhan professor and hod of surgery dr snmc,jodhpur candidatedr sumer 2. Possibility of cholangiocarcinoma should always be kept in mind while dealing with patients presenting with delayed biliary stricture. The main etiology of bile duct strictures closely related to the liver is a malignancy cancer. The mean sensitivities of ercp and eusfna for tissue diagnosis of malignant biliary stricture were 49% and 75%, respectively. Newly developed fully covered metal stent for unresectable.
Pdf radiofrequency and malignant biliary strictures. In patients with extrahepatic malignancies, uncovered. Pdf covered metal stenting for malignant lower biliary. Comparing available cholangioscopes on diagnosis of malignant. Biliary stricture is a term used to describe a constriction of the bile duct, a tube which carries bile from the liver and the gallbladder to the intestines. It is now possible to manage most extrahepatic bile duct strictures, benign or malig nant, using endoscopic retrograde cholangiopan creatography ercp with endoscopic. In contrast, malignant strictures are usually irregular, asymmetrical and of longer.
The diagnosis of biliary strictures can be challenging. A biliary stricture is a narrowing of the common bile duct. The most pertinent and critical differentiation is between benign and. When this happens, bile can back up into the liver, causing abdominal pain, nausea, itching, fever, chills, and jaundice. In terms of its location, the distal biliary stricture was further categorized into two subgroups. Traditionally, biliary strictures have been considered to be indeterminate when a diagnosis cannot be made after basic laboratory workup, abdominal imaging and endoscopic retrograde cholangiopancreatography ercp with biliary sampling. Of these, 170 patients had no definitive mass on computed tomography and 172 patients had definitive mass on computed tomography without evidence of unresectability. Patients with biliary strictures due to operative injury, radiation, trauma, or chronic pancreatitis generally have a good prognosis. The standards of practice committee of the american society for gastrointestinal endoscopy asge prepared this text. Endoscopic stenting is a widely accepted strategy for providing effective drainage in both extrahepatic and intrahepatic malignant strictures. Jeffery wiernan, md, louisville, kentucky background.
Tubercular biliary stricture a malignant masquerade. In spite of the wider caliber of a selfexpandable metal stent sems, which has a longer stent patency than that of plastic stents 15, occlusion by tumortissue ingrowth can develop due to the meshwork design. Endoscopic management of malignant biliary stenosis. Postcholecystectomy bile duct stricture can develop even after several years of index surgery.
The significance of biliary strictures without jaundice is less certain and a much lower proportion of these are malignant. Patients with obstructive jaundice and biliary stricture. Endoscopic retrograde cholangiopancreatography versus. Endoscopic treatment of malignant biliary strictures. The endoscopic management of these patients has changed, both with time and with improvements in medical devices. How to differentiate benign from malignant bile duct. Approach to management of indeterminate biliary stricture juniper. A stent was placed across the stricture, which sealed the fistula. Biliary strictures bs are an everyday challenge in gastrointestinal clinical prac tice.
Management endoscopic surgery with insertion of selfexpanding metal mesh stents. Novel 7mmdiameter double bare metal stent for endoscopic. Endoscopic management of benign and malignant biliary. Benign obstruction is most commonly caused by choledocholithiasis. The analysis was a qualitative synthesis of data from 29 prospective studies comprising 1141 patients.
Endoscopic biliary drainage in malignant high grade biliary. Comparing available cholangioscopes on diagnosis of. Bile duct stricture biliary stricture is an uncommon but challenging clinical condition that requires a coordinated multidisciplinary approach involving gastroenterologists, radiologists, and surgical specialists. The chart showing pdf series, word series, html series, scan qr codes. Biliary strictures at the hilum of the liver arise from heterogeneous etiologies. In western countries, iatrogenic stricture is the most common benign biliary stricture and accounts for up to 80% of all benign strictures 1, 2.
Endoscopic management of benign and malignant biliary strictures. The role of ercp in benign diseases of the biliary tract. Benign and malignant biliary obstructions are difficult to differentiate with imaging alone. Bile is a substance that helps in digestion of fatty food. Diagnosis of malignant biliary strictures, techniques in. Biliary endoscopy for benign and malignant biliary strictures article pdf available in techniques in vascular and interventional radiology 223 may 2019 with reads how we measure reads. Eus can also reliably identify alternative etiologies of biliary stricture that do not require surgery, such as periportal lymph node enlargement with malignant infiltration, including those due to lymphoma, lymphomatous involvement of the pancreas or metastatic lesions to the pancreas, especially from the lung and kidney. Endoscopic stent placement is an efficacious treatment for patients with malignant biliary stricture. Improvements in existing technologies as well as the implementation of novel technologies and techniques have the potential to. Tissue sampling at ercp in suspected malignant biliary strictures part 1. Final determination of malignancy in biliary strictures can entail major surgery if preoperative diagnosis of malignancy cannot be made. Biliary strictures frequently present a challenge in terms of diagnosis, which requires a multidisciplinary approach. Biliary stricture can be seen with a wide array of nonneoplastic causes. Background biliary strictures bs are an everyday challenge in gastrointestinal clinical practice.
Both stents were removed and occlusive retrograde cholangiography indicated that the biliary stricture was resolved, figure 7. Clinical findings jaundice, fever, chills, abdominal pain. Endoscopic biliary drainage had been indicated in malignant biliary. Surgery choledochojejunostomy or hepaticojejunostomy has traditionally been the treatment of choice for benign extrahepatic bile duct stricture with a success rate of up to 90% reported. In preparing this guideline, a search of the medical litera.
However, the diagnostic yield from conventional endoscopic retrograde cholangiopancreatography tissue sampling is modest. The endoscopic management of these patients has changed, both with time and with improvements in medical. Diagnosis of malignant biliary strictures diagnosis of malignant biliary strictures lin, anthony. However, the differentiation of benign and malignant strictures is notoriously difficult. The primary surgical approach is, however, associated with a significant increased incidence of early complications 26% vs 8% and cannot be performed in all patients. Biliary endoscopy for benign and malignant biliary strictures. Malignant biliary strictures represent a diagnostic and therapeutic open. Role of mrcp in differentiation of benign and malignant. Pdf tubercular biliary stricture a malignant masquerade. To evaluate the need for endoscopic sphincterotomy est before covered selfexpandable metal stent csems deployment for malignant lower biliary stricture with pancreatic duct obstruction. The diagnosis of biliary stricture is often missed or delayed because of its indolent course, with up to 20% of patients presenting with subtle clinical manifestations 1 year after the initial injury. Percutaneous y biliary stent placement in palliative treatment of type 4 malignant hilar stricture backgroundaim. Listing a study does not mean it has been evaluated by the u.
Oct 23, 2018 biliary strictures can be broadly classified as benign or malignant. A repeat ercp showed a long segment of stricture in the mid cbd with filling of an apparent single duct superior to the stricture. Endoscopy has an established role in the diagnosis and therapy of biliary strictures. It is difficult to distinguish between malignant and benign biliary strictures preoperatively.
Diagnosis of malignant biliary strictures sciencedirect. Brush cytology of biliary strictures is common practice at ercp but has low sensitivity for cancer detection. Unfortunately, most benign bile duct strictures biliary strictures are iatrogenic, resulting from operative trauma see images. Conversely, patients with bile duct strictures due to psc and malignancy have a less favorable outcome. Endoscopic management of benign and malignant biliary strictures gary c.
However, a disadvantage of using uncovered selfexpandable metal stents is the. Endoscopic biliary drainage in malignant high grade. Endoscopic palliation of malignant biliary strictures. It is important to determine the benign or malignant nature of a biliary stricture, and a tissue diagnosis is usually desirable. Among liver hilum malignancies primary cholangiocarcinoma is the. This article discusses methods for diagnosis of malignant biliary strictures, including.
The etiology of malignant biliary stenosis varies accord ing to localization. Cholangiocarcinoma and adenocarcinoma of the pancreas are the most common causes of malignant biliary obstruction. Oct 28, 2014 eus can also reliably identify alternative etiologies of biliary stricture that do not require surgery, such as periportal lymph node enlargement with malignant infiltration, including those due to lymphoma, lymphomatous involvement of the pancreas or metastatic lesions to the pancreas, especially from the lung and kidney. Endoscopic palliation of malignant biliary strictures introduction biliary strictures should be considered in any patient presenting with clinical signs such as jaundice, pale stool, dark urine and pruritus. Mb management of benign biliary strictures should be aimed at achieving patency of the bile duct or preserving that patency in an attempt to minimize any short or longterm complications such as infection with cholangitis or more chronic changes such as secondary biliary cirrhosis. The pretest probability for malignant biliary stricture was 76. Mucosaassociated lymphoid tissue malt lymphoma as an.
It has been reported that 515 % of preoperative diagnoses of hilar cholangiocarcinoma turn out to be benign lesions or even. In fact, stricture formation can be delayed beyond 5 years in up to onethird of cases. Benign biliary strictures pose difficult management problems. Malignant biliary strictures are usually linked to different types of tumors, mainly cholangiocarcinoma, pancreatic and hepatocellular carcinomas. Improvements in existing technologies as well as the implementation of novel technologies. Transpapillary biliary biopsy for malignant biliary. In contrast to malignant biliary obstruction, in which shortterm palliation is often the goal of therapy, benign strictures require durable repair because most patients are in otherwise good health and are expected to live for years. In case of malignant biliary stricture with jaundice eus biliary drainage is a wonderful tool in case of failure of ercp high technical success high clinical success tolerable rate of adverse events specific technical skills and training replace the ptbd if available. Stenting for benign and malignant biliary strictures gastrointestinal.
Malignant biliary strictures are usually linked to different types of. Endoscopic biliary drainage in malignant high grade biliary stricture the safety and scientific validity of this study is the responsibility of the study sponsor and investigators. Pdf tissue sampling at ercp in suspected malignant. Cholecystectomy and orthotopic liver transplantation olt are the most common iatrogenic causes of benign biliary stricture. A narrowed bile duct makes it difficult for bile to pass to the small bowel, causing a buildup of bile. Benign biliary stricture accounts for significant morbidity and mortality and is difficult to treat. An irregular tract was also noted emptying laterally into the hepatic flexure, suggestive of a biliarycolic fistula figure 2. Pdf on mar 31, 2018, hyun jik lee and others published diagnosis of malignant biliary stricture. This study evaluated the technical and clinical efficacy of percutaneous bilateral biliary stentinstent sis deployment technique with a y configuration using opencelldesign stents in type 4 klatskin tumor patients. Endoscopic management of a benign biliary stricture. Pathology etiology there are numerous causes of biliary duct strictures, including 1,2. Stricture recurrence after dilatation may be reduced by placement of a biliary stent. Strictures can be caused during surgery on nearby tissues, such as the gallbladder. Once confirmed, a crucial step in the workup includes differentiating between malignant and benign etiologies.
Oct 16, 2019 bile duct stricture biliary stricture is an uncommon but challenging clinical condition that requires a coordinated multidisciplinary approach involving gastroenterologists, radiologists, and surgical specialists. Alhough up to 30% of biliary strictures can be benign 1, the vast majority are malignant, the two major malignancies being pancreatic. Aetiology prior local surgery, pancreatitis, trauma, gallstones. See usefulness of endoscopic transpapillary tissue sampling for malignant biliary strictures and predictive factors of diagnostic accuracy. Alhough up to 30% of biliary strictures can be benign, the vast majority are malignant, the two major malignancies being pancreatic adenocarcinoma and cholangiocarcinoma.
Current endoscopic management of malignant biliary stricture. Biliary biopsy, biliary stricture, cholangiocarcinoma, pancreatic cancer background biliary stricture may be benign or malignant. Biliary stricture occurs when the bile duct the tube that takes bile from the liver to the small bowel gets smaller or narrower. Biliary stenting biliary obstruction malignant biliary obstruction. Bile duct strictures are problematic in terms of management and distinction between benign and malignant. Yield of ercp tissue sampling of malignant biliary. Bile duct stricture definition of bile duct stricture by. There is a wide spectrum of nonneoplastic causes of biliary stricture that can pose a significant challenge to clinicians and radiologists. Differentiating malignant from benign common bile duct.
Postcholecystectomy partial biliary stricture leading to. Biliary strictures can be broadly classified as benign or malignant. It is estimated that almost 20% of the subclinical jaundice is due to malignant bile duct obstruction, divided by a ratio of 2. The increased use of endoscopic biliary evaluation and intervention has modified. Percutaneous y biliary stent placement in palliative. Endoscopic biliary stenting is an efficacious treatment for patients with unresectable malignant biliary stricture. It is now possible to manage most extrahepatic bile duct strictures, benign or malig nant, using endoscopic retrograde cholangiopan creatography ercp with endoscopic dilatation and stenting. Asiapacific consensus guidelines for endoscopic management of. The investigators define this malignant high grade biliary stricture using these arbitrary number include total bilirubin. Patients with obstructive jaundice and biliary stricturemass. A number of factors can cause the bile duct to become constricted, including gallstones, scar tissue, pancreatitis, tumors, and a condition known as primary sclerosing cholangitis.
Malignant high grade biliary stricture has not been well defined. The role of ercp in benign diseases of the biliary tract this is one of a series of statements discussing the use of gi endoscopy in common clinical situations. As palliation for malignant hilar biliary obstruction mhbo, both endoscopic stentinstent and sidebyside sbs stent placement are similarly effective. When these diseases become symptomatic, biliary obstruction, either with or without infection, occurs frequently due to the anatomy associated with these cancers. We investigated the indications for plastic stent placement in patients with unresectable malignant biliary stricture. All bile duct strictures in patients with obstructive jaundice should be considered malignant unless a benign etiology is definitively identifiable. Patients with biliary strictures underwent triple tissue sampling at 1. The major etiology of a malignant biliary stricture includes a primary tumor or local extension, such as cholangiocarcinoma or pancreatic head cancer 1. Differential diagnosis of benign and malignant distal. A recent large series reported that ercpintraductal ultrasound idus 91% was superior to eus 74% and ct 73% in providing an accurate diagnosis of bile duct strictures of uncertain aetiology.
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