Tips and tricks for the diagnosis and management of biliary stenosis-state of the art review

Abstract

Biliary stenosis may represent a diagnostic and therapeutic challenge resulting in a delay in diagnosis and initiation of therapy due to the frequent difficulty in distinguishing a benign from a malignant stricture. In such cases, the diagnostic flowchart includes the sequential execution of imaging techniques, such as magnetic resonance, magnetic resonance cholangiopancreatography, and endoscopic ultrasound, while endoscopic retrograde cholangiopancreatography is performed to collect tissue for histopathological/cytological diagnosis or to treat the stenosis by insertion of stent. The execution of percutaneous transhepatic drainage with subsequent biopsy has been shown to increase the possibility of tissue diagnosis after failure of the above techniques. Although the diagnostic yield of histopathology and imaging has increased with improvements in endoscopic ultrasound and peroral cholangioscopy, differential diagnosis between malignant and benign stenosis may not be easy in some patients, and strictures are classified as indeterminate. In these cases, a multidisciplinary workup including biochemical marker assays and advanced technologies available may speed up a diagnosis of malignancy or avoid unnecessary surgery in the event of a benign stricture. Here, we review recent advancements in the diagnosis and management of biliary strictures and describe tips and tricks to increase diagnostic yields in clinical routine.

Keywords: Biliary stenosis; Cholangioscopy; Metal stent; Endoscopic ultrasound; Endoscopic ultrasound-guided fine needle aspiration; Biliary stenosis treatment

Core Tip: Biliary stenosis remains a diagnostic and therapeutic challenge due to the difficulty in obtaining a tissue diagnosis to differentiate a malignant from a benign stricture. The diagnostic and therapeutic workup of patients with a suspected malignant biliary stricture should be discussed at a multidisciplinary team meeting in a tertiary center. The use of all available diagnostic tools such as magnetic resonance cholangiopancreatography, endoscopic retrograde cholangiopancreatography, endoscopic ultrasound-fine needle aspiration, and cholangioscopy should be evaluated to avoid unnecessary surgery or a delay in diagnosis. Here, we focus on the most recently published findings regarding the diagnosis and therapy of biliary stricture.