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 :

• malignant
  • cholangiocarcinoma
  • involvement by pancreatic head adenocarcinoma
  • involvement by ampulla of Vater adenocarcinoma
  • involvement by gallbladder carcinoma
• benign
  • iatrogenic strictures
    • diathermy burns
    • hemostasis clips
    • suture granuloma
    • amputation neuroma of the cystic duct
    • previous anastomosis (e.g. post liver transplant)
  • primary sclerosing cholangitis
  • Mirizzi syndrome
  • chronic pancreatitis
  • previous stone passage

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:

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)

Siehe auch:

• Chronische Pankreatitis
• Primär sklerosierende Cholangitis
• cholangiozelluläres Karzinom
• Choledochuskarzinom
• Mirizzi-Syndrom
• Tumoren der intrahepatischen Gallenwege
• pancreatic head adenocarcinoma

und weiter:

• sclerosing cholangitis
• PTC
• distal common bile duct stricture
• post-operative biliary stricture