John Libbey Eurotext

Hépato-Gastro & Oncologie Digestive

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Biliary strictures: diagnosis and treatment Volume 21, issue 8, Octobre 2014

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Author
Hôpital Européen Georges Pompidou,
service de gastro-entérologie,
20 rue Leblanc,
75015 Paris,
France ;
Hôpital Privé,
1 rue Velpeau,
92160 Antony,
France

Biliary strictures are typically revealed by jaundice or cholangitis. Diagnosis might be obvious regarding to the context and first line imaging by computed tomography (CT): either malignant (pancreatic cancer, intrahepatic or lymph node compressive metastasis) or benign (complication after cholecystectomy or biliary surgery). Without this kind of orientation, cholangiocarcinoma is suspected but diagnosis is usually more difficult to assess. These strictures remain a diagnostic dilemma since a significant proportion of them remain indeterminate for malignancy despite a first line of imaging procedures including magnetic resonance cholangiopancreatography, endoscopic ultrasonography, ± fine needle aspiration and endoscopic retrograde cholangiopancreatography with cytology brush and trans-papillary biopsies. The difficulty is amplified when attempting to discern malignant from non-malignant strictures in patients with primary sclerosing cholangitis or chronic pancreatitis, since both inflammatory and tumoral biliary strictures can occur. In case of an indeterminate biliary stricture, more specific techniques can be combined to assess the diagnosis: cholangioscopy, possibly optimized by the use of probe-based confocal laser endomicroscopy, allowing targeted biopsies. Regarding the treatment of biliary strictures, few patients are eligible for surgery and stent placement is commonly used, mostly during an ERCP procedure. In case of a benign or indeterminate stricture, removable, plastic or fully covered metallic stents are used. For malignant strictures, metallic stents, mostly uncovered, allow a durable relief of jaundice.