biliary strictures

Bile duct strictures are problematic in terms of management and distinction between benign and malignant.

Pathology

Etiology

There are numerous causes of biliary duct strictures, including :

Although identification of malignant cells on washings obtained during ERCP can make the diagnosis, they are negative in 25-50% of cases . Careful imaging is therefore often required.

Carcinoembryonic antigen (CEA) and CA 19-9 are sometimes secreted by cholangiocarcinomas.

Radiographic features

The distinction between malignant and benign structures relies on two aspects:

  • morphology of the stricture
  • associated findings, pointing to a cause
  • As far as assessing the morphology of the stricture, modalities that image the lumen (ERCP, MRCP, CT intravenous cholangiograms) are best, whereas to assess for associated features US or CT/MRI are better.

    Stricture morphology

    Benign features include :

    • smooth
    • tapered margins

    Malignant features include:

    • irregular
    • shouldered margins
    • thickened (>1.5 mm) and enhancing (on arterial and or portal venous phase) duct walls

    It is often difficult to distinguish between malignant and benign strictures, especially if short .

    Associated findings

    Associated findings are for example:

    • features of chronic pancreatitis
    • evidence of previous cholecystectomy
    • lymph node enlargement
    • infiltrating mass

    Treatment and prognosis

    Treatment and prognosis clearly depend on the underlying etiology.

    For benign stricture and number of options exist, including:

    • cholangioplasty: percutaneous or retrograde balloon dilation
    • stent placement: only considered in failed cholangioplasty and no other surgical options
    • surgery with resection of the stenotic segment and re-anastomosis or choledochoenterostomy (e.g. Roux-en-Y)
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