Surveillance of primary sclerosing cholangitis with ERC and brush cytology: risk factors for cholangiocarcinoma

Objective: Primary sclerosing cholangitis (PSC) is a chronic cholestatic liver disease leading to bile duct strictures and fibrosis, and predisposing to cholangiocarcinoma (CCA). Biliary dysplasia is a known precursor of CCA. In our unit, PSC patients undergo regular surveillance with ERC and brush cytology (BC), and liver transplantation is an option in case with biliary dysplasia. We evaluated the risk factors for biliary dysplasia and CCA based on ERC imaging, BC and liver function tests.

Patients and methods: Seven hundred and eighty-eight ERCs were performed with BC for 447 PSC patients. ERC images were evaluated using the modified Amsterdam score, neutrophilic inflammation was assessed in BC, and liver function tests were collected. Ploidy analysis with DNA flow cytometry was performed in cases with advanced PSC or previous suspicious BC/aneuploidy. The endpoint was either a benign disease course (follow-up for ≥2.4 years after the latest ERC), benign histology, biliary dysplasia or CCA.

Results: Benign disease course was seen in 424/447 (including 23 cases with biliary dysplasia), and CCA in 17 (3.8%) patients. Gallbladder carcinoma/carcinoma in situ was diagnosed in three patients. Advanced ERC findings, male gender, suspicious BC, aneuploidy in flow cytometry, inflammation, and elevation of ALP, bilirubin, ALT, AST, GGT, CEA and CA19-9 represented significant risk factors for CCA in univariate analysis.

Conclusions: PSC patients with advanced bile duct disease and elevated liver enzymes, CEA or CA19-9, inflammation or suspicious BC are most likely to develop CCA. These patients may benefit from surveillance with BC if early liver transplantation is possible.     

Role of fluorescence in situ hybridization in diagnosing cholangiocarcinoma in indeterminate biliary strictures

Background and Aim

Brush cytology, the conventional method to diagnose cholangiocarcinoma, has been plagued by low diagnostic sensitivity and false‐negative results. This paper aims to study the clinical utility of fluorescence in situ hybridization (FISH) in enhancing identification of malignant biliary strictures.

Methods

Brush cytologic specimens collected from endoscopic retrograde cholangiopancreatography for biliary strictures in a tertiary hospital in Singapore from March 2013 to July 2015 were examined by FISH technique using UroVysion probe set in this study.

Results

Thirty patients were chosen with five patients having multiple FISH performed due to indeterminate results. The diagnoses for biliary strictures were 13 (43.3%) cholangiocarcinomas, seven (23.3%) pancreatic cancers, seven (23.3%) benign biliary strictures, and three (10%) primary sclerosing cholangitis. Conventional brush cytology had sensitivity of 53.8% with specificity of 82.4%. FISH had sensitivity of 30.8% with specificity of 100%. When FISH results were interpreted in cases with negative or atypical brush cytology, two patients had positive FISH results and cholangiocarcinomas. Based on this pilot study, FISH increased sensitivity of brush cytology in detection of cholangiocarcinoma from 53.8% to 69.2% while preserving specificity of 82.4%.

Conclusion

Compared with conventional cytology with low sensitivity, FISH may help to increase sensitivity on top of brush cytology while maintaining high specificity.     

SPECIFIC DIAGNOSIS OF BILIARY STRICTURES BY QUANTITATIVE ASSESSMENT USING A CHOLANGIOSCOPICALLY DERIVED HEMOGLOBIN INDEX

Background: We used percutaneous transhepatic cholangioscopy for detailed assessment of biliary tumors. Among the most important endoscopic findings is greater mucosal vascularity in malignant than in benign biliary strictures. Development of digital image processing now permits measurement of mucosal hemoglobin volume as a hemoglobin index. We studied the clinical usefulness of this hemoglobin index for differentiating malignant from benign biliary strictures. Methods: From 2000 to 2002 we determined the hemoglobin index in 22 patients with biliary stricture (8 with bile duct carcinoma; 1 with carcinoma of the duodenum; 5 with pancreatic carcinoma and 8 with benign stricture). Eight patients with malignant stricture were diagnosed by the histological examinations of resected specimens; six with malignant stricture and eight with benign stricture were diagnosed by examination of biopsy specimens. The ratio of hemoglobin indices in a given patient of lesional and uninvolved mucosa was determined from cholangioscopic imaging data. Results: The mean hemoglobin index ratio for bile duct carcinoma was 1.83; for carcinoma of the duodenum 1.98; and for pancreatic carcinoma, 1.35. For benign strictures, the ratio was only 1.09. The mean hemoglobin index ratio in patients with bile duct or pancreatic carcinoma was significantly higher than in patients with benign stricture (P < 0.05, paired t‐test). Conclusions: An image‐derived hemoglobin index is useful for diagnostic assessment of biliary stricture.     

Prospective evaluation of advanced molecular markers and imaging techniques in patients with indeterminate bile duct strictures

BACKGROUND AND  AIMS: Standard techniques for evaluating bile duct strictures have poor sensitivity for detection of malignancy. Newer imaging modalities, such as intraductal ultrasound (IDUS), and advanced cytologic techniques, such as digital image analysis (DIA) and fluorescence in situ hybridization (FISH), identify chromosomal abnormalities, and may improve sensitivity while maintaining high specificity. Our aim was to prospectively evaluate the accuracy of these techniques in patients with indeterminate biliary strictures.
METHODS: Cholangiography, routine cytology (RC), intraductal biopsy, DIA, FISH, and IDUS were performed in 86 patients with indeterminate biliary strictures. Patients were stratified based on the presence or absence of primary sclerosing cholangitis (PSC).
RESULTS: RC provided low sensitivity (7–33%) but high specificity (95–100%) for PSC and non-PSC patients. The composite DIA/FISH results (when considering trisomy-7 [Tri-7] as a marker of benign disease) yielded a 100% specificity and increased sensitivity one- to fivefold in PSC patients versus RC, and two- to fivefold in patients without PSC, depending on how suspicious cytology results were interpreted. For the most difficult-to-manage patients with negative cytology and histology who were later proven to have malignancy (N = 21), DIA, FISH, composite DIA/FISH, and IDUS were able to predict malignant diagnoses in 14%, 62%, 67%, and 86%, respectively.
CONCLUSIONS: DIA, FISH, and IDUS enhance the accuracy of standard techniques in evaluation of indeterminate bile duct strictures, allowing diagnosis of malignancy in a substantial number of patients with false-negative cytology and histology. These findings support the routine use of these newer diagnostic modalities in patients with indeterminate biliary strictures.     

Vascular Endothelial Growth Factor Levels in Bile Distinguishes Pancreatic Cancer from Other Etiologies of Biliary Stricture: A Pilot Study

Background

Determining the benign or malignant nature of biliary strictures can be challenging. Vascular endothelial growth factor (VEGF) plays an important role in tumor angiogenesis.

Objective

The purpose of this study was to investigate whether VEGF levels in bile aspirated during endoscopic retrograde cholangiography (ERCP) can distinguish pancreatic cancer from other causes of biliary stricture.

Methods

Bile was directly aspirated in 53 consecutive patients from March 2012 to October 2012 during ERCP from the common bile duct including 15 with pancreatic cancer, 18 with primary sclerosing cholangitis (PSC), nine with cholangiocarcinoma (CCA), and 11 with benign biliary conditions (sphincter of Oddi and choledocholihiasis). Levels of VEGF in bile were measured. The diagnostic performance was then validated in a second, independent validation cohort of 18 patients (pancreatic cancer n = 10, benign n = 8).

Results

A total of 53 consecutive patients were recruited. The median bile VEGF levels were significantly elevated in patients with pancreatic cancer (1.9 ng/ml (interquartile range [IQR] 0.7, 2.2) compared to those with benign biliary conditions (0.3 ng/ml [IQR 0.2, 0.6]; p < 0.001), PSC (0.7 ng/ml [IQR 0.5, 0.9]; p = 0.02) or CCA (0.4 ng/ml [IQR 0.1, 0.5]; p < 0.001). A VEGF cut-off value of 0.5 ng/ml distinguished pancreatic cancer from CCA with a sensitivity and specificity of 93.3 and 88.9 %, respectively, and area under curve (AUC) of 0.93, and from benign conditions with a sensitivity and specificity of 93.3 and 72.7 %, respectively, with AUC of 0.89. The diagnostic accuracy of biliary VEGF was confirmed in the second independent validation cohort.

Conclusions

This study suggests that measurement of biliary VEGF-1 levels distinguishes patients with pancreatic cancer from other etiologies of biliary stricture. This may be particularly relevant in approaching patients with indeterminate biliary stricture.     

Pancreatic duct changes are not associated with early signs of chronic pancreatitis at magnetic resonance imaging (MRI) in patients with primary sclerosing cholangitis

Abstract

Objective. The association between chronic pancreatitis (CP) and primary sclerosing cholangitis (PSC) has been reported previously. The aims of the present study were to evaluate the presence of early pancreatic abnormalities and duct changes, using MRCP/MRI in PSC and to evaluate possible risk factors for these changes and their clinical importance. Materials and methods. One hundred and three patients with PSC were identified among all MRI liver/pancreas referrals in 2001–2005. MRCP was used to grade pancreatic duct changes in three groups: grade 0 (normal), grade 1 (mild) and grade 2 (severe). For detection of early MRI signs of CP, the pancreas-spleen signal intensity ratio (SIR), the arterial and early venous phase ratio (A/PV ratio) and the age-related size of the pancreas were evaluated. Results. Pancreatic duct changes were found in 24% of the PSC patients. The pancreatic duct changes were associated with extrahepatic biliary involvement and long duration of PSC but not associated with pancreas-spleen SIR, A/PV ratio, pancreas size, previous post-ERCP or acute pancreatitis. Severe pancreatic duct changes were significantly associated to abdominal pain. Clinically significant CP was seen in one PSC patient (1%). Conclusions. Pancreatic duct changes are associated with extrahepatic bile duct strictures and not with the early MRI signs of CP. Therefore, pancreatic duct changes seem to be part of the spectrum of PSC and should not be defined as CP. Pancreatic duct changes are of limited clinical importance but may contribute to abdominal pain in PSC.     

Spyglass single-operator peroral cholangioscopy seems promising in the evaluation of primary sclerosing cholangitis-related biliary strictures

Abstract

Early diagnosis of dysplastic changes and exclusion of cholangiocarcinoma (CCA) in patients with primary sclerosing cholangitis (PSC) remain a major clinical challenge. Although SpyGlass single-operator cholangioscopy (SOC) appears effective in diagnostics of indeterminate biliary strictures, there are only few studies on its safety in PSC-related strictures. Objective. The aim of this study was to assess the clinical feasibility of SOC and directed biopsies, flow cytometry, and brush cytology in PSC patients. Materials and methods. Eleven consecutive patients (median age 45 years, 5 females) undergoing SOC for progression of PSC in a single tertiary center were included in a prospective observational study. Results. Brush sample and directed biopsies were successfully acquired from strictures in all cases. Samples were adequate for cytological and histological diagnosis in 9 (82%) and 10 patients (91%), respectively. There were two cases of pancreatitis. In one patient, flow cytometry showed aneuploidy, which resulted in closer follow-up. Conclusions. SpyGlass SOC and directed biopsies seem to offer a feasible and promising method in evaluation of PSC-related strictures. However, the long-term prognostic value it adds to cytology and flow cytometry remains to be assessed in future trials.     

Diagnosis and endoscopic management of primary sclerosing cholangitis

Primary sclerosing cholangitis (PSC) is a complex, chronic, and progressive fibroinflammatory destructive cholestatic biliary disease. The exact etiology and pathogenesis are unknown and possibly related to an enhanced immune-mediated response and reaction in the biliary system. PSC is closely associated with inflammatory bowel disease and specifically, ulcerative colitis. It can be characterized by both intrahepatic and extrahepatic bile duct stricturing and dilation. Clinical manifestations include abnormal liver tests, jaundice, pruritus, and fatigue. At more advanced stages, PSC can progress to cirrhosis and posttransplant disease recurrence is not uncommon. PSC is associated with an increased risk of cholangiocarcinoma and is an independent risk factor for colorectal cancer in patients with concomitant inflammatory bowel disease. Cholangiography is the mainstay of PSC diagnosis. Improved noninvasive biliary imaging has shifted the role of endoscopic retrograde cholangiopancreatography from disease diagnosis to management of complications, including dominant biliary strictures, bile duct stones, and assisting in the differentiation of benign vs malignant strictures. The role of additional endoscopic modalities, including endoscopic ultrasound, direct cholangioscopy, and probe-based confocal laser endomicroscopy is evolving. At the present time, medical treatment options are limited and the role of endoscopy is mainly supportive.     

ENDOSCOPIC TREATMENT FOR THE BENIGN BILIARY STRICTURE IN THE PATIENT WITH CHRONIC PANCREATITIS

In some patients with chronic pancreatitis (CP), strictures are observed in the intrapancreatic bile ducts due to fibrosis and inflammation in the pancreas. Normally, even when biliary strictures exist, obstructive jaundice is rarely observed. It seemed that obstructive jaundice was brought about by temporary pancreatitis due to immoderate alcohol ingestion, followed by the aggravation of the intrapancreatic biliary stricture. When immoderate alcohol ingestion is incriminated for the pancreatic disorder, the patient should be strictly instructed to abstain from alcohol, but failure to observe this instruction seems to render endoscopic biliary stenting ineffective. When CP is complicated with pancreatolithiasis, stone fragmentation using extracorporeal shock wave lithotripsy (ESWL) is effective, and combination with endoscopic lithotomy makes it possible to remove pancreatic stones in the main pancreatic duct (MPD). To treat the beside dilating stricture of the MPD, balloon dilation and pancreatic duct stenting are performed. We obtained good results with 10 Fr pancreatic duct stents, but biliary strictures are better treated with a combination of these methods. When 10 Fr or larger straight biliary stents are used, they may be dislodged or stray if the bile duct is sharply curved. To prevent this accident we have used 10 Fr double layer stents and obtained good results. In patients with benign biliary strictures, stents are temporarily placed and should be removable. Some cases have been reported where Wallstent gave good results in a short period, but the stents were occluded due to hyperplastic proliferation of the biliary epithelium. Metal stents are not considered desirable for benign biliary strictures. Our results seem to support the assumption that benign biliary strictures are improved with 10 Fr or larger biliary stents while exercizing care to keep the patient abstinent from alcohol and performing ESWL and endoscopic treatment for CP.     

Diagnosis and management of primary sclerosing cholangitis-perspectives from a therapeutic endoscopist

Primary sclerosing cholangitis(PSC) is a chronic,cholestatic liver condition characterized by inflammation,fibrosis,and destruction of the intra-and extrahepatic bile ducts.The therapeutic endoscopist plays a key role in the diagnosis and management of PSC.In patients presenting with a cholestatic profile,endoscopic retrograde cholangiopancreatography(ERCP) is warranted for a definite diagnosis of PSC.Dominant strictures of the bile duct occur in 36%-57% of PSC patients.Endoscopic balloon dilatation with or without stenting have been employed in the management of dominant strictures.In addition,PSC patients are at increased risk of developing cholangiocarcinoma with a 20% lifetime risk.Brush cytology obtained during ERCP and use of fluorescence in situ hybridization forms the initial diagnostic step in the investigation of patients with dominant biliary strictures.Our review aims to summarize the current evidence supporting the role of a therapeutic endoscopist in the management of PSC patients.     

Endoscopic management of primary sclerosing cholangitis

Introduction: Primary sclerosing cholangitis (PSC) is a rare but clinically important cholestatic liver disease. Histopathologically and cholangiographically, PSC is characterized by intra- and/or extra-hepatic bile duct inflammation and fibro-obliteration, which ultimately leads to biliary cirrhosis and related sequelae, including development of hepatobiliary and colorectal carcinomata. PSC can be diagnosed at essentially any age and carries a median survival of 15–20 years, regardless of age at diagnosis, and is a foremost risk factor for cholangiocarcinoma. Given the chronic and progressive nature of PSC, its inherent association with both neoplastic and non-neoplastic biliary tract complications, and the lack of effective pharmacotherapies, alimentary and biliary tract endoscopy plays a major role in the care of patients with PSC.

Areas covered: Here, we provide a narrative review on endoscopic management of PSC, including established and evolving applications to the diagnosis and treatment of both its benign and malignant complications.

Expert commentary: Due to the rarity of PSC and the considerable patient-years required to rigorously study major endpoints, there remains a paucity of high-quality evidence regarding its management. As the advanced endoscopic repertoire expands, so has the interest in developing best practices in PSC, which we discuss herein.     

Clinical clues to suspicion of IgG4-associated sclerosing cholangitis disguised as primary sclerosing cholangitis or hilar cholangiocarcinoma

Background and Aim: This study aimed to determine the clinical characteristics of immunoglobulin G4 (IgG4)‐associated sclerosing cholangitis (ISC) and provide clinical clues differentiating ISC from primary sclerosing cholangitis (PSC) or hilar cholangiocarcinoma (CCC). Methods: Sixteen patients with ISC manifesting as hilar/intrahepatic strictures were analyzed for clinical characteristics and compared with patients with PSC and hilar CCC as disease controls for histology and serum IgG4 levels. Results: Distinguished biliary imaging findings of ISC included multifocal biliary tree involvement (n = 14), concentric bile duct thickening with preserved luminal patency (n = 13), and relatively mild proximal dilatation, despite prominent bile duct thickening (n = 11). Serum IgG4 levels were elevated in 12 patients (75%), but not in any of the 25 patients with hilar CCC. Ten patients (63%) had a past or concurrent history of autoimmune pancreatitis (AIP). The significant infiltration of IgG4‐positive cells was observed with endobiliary or liver biopsy in 11 of 16 patients (69%) with ISC, but not in any patients with PSC or hilar CCC. Extrabiliary organ involvement, including sialadenitis, inflammatory pseudotumor of the liver and kidney, and retroperitoneal fibrosis, was present in seven patients. Marked improvement of biliary strictures and/or extrabiliary involvement was observed in all ISC patients after steroid therapy. Conclusions: ISC should be considered in the differential diagnosis of hilar/intrahepatic biliary strictures. Past or concurrent AIP or extrabiliary organ involvement strongly suggests the possibility of ISC. Significant infiltration of IgG4‐positive cells on endobiliary or liver biopsy specimens, and/or elevated serum IgG4 levels, highly support the diagnosis of ISC and provide the rationale for steroid therapy.     

Current endoscopic approach to indeterminate biliary strictures

Biliary strictures are considered indeterminate when basic work-up, including transabdominal imaging and endoscopic retrograde cholangiopancreatography with routine cytologic brushing, are non-diagnostic. Indeterminate biliary strictures can easily be mischaracterized which may dramatically affect patient’s outcome. Early and accurate diagnosis of malignancy impacts not only a patient’s candidacy for surgery, but also potential timely targeted chemotherapies. A significant portion of patients with indeterminate biliary strictures have benign disease and accurate diagnosis is, thus, paramount to avoid unnecessary surgery. Current sampling strategies have suboptimal accuracy for the diagnosis of malignancy. Emerging data on other diagnostic modalities, such as ancillary cytology techniques, single operator cholangioscopy, and endoscopic ultrasonography-guided fine needle aspiration, revealed promising results with much improved sensitivity.     

Primär sklerosierende Cholangitis

Primary sclerosing cholangitis (PSC) is a chronic progressive cholestatic disease leading to multiple strictures of the extra- and intrahepatic bile ducts and to biliary cirrhosis. The majority of patients are young men who also suffer from inflammatory bowel disease. The risk of cholangiocarcinoma and of colorectal cancer is significantly increased. PSC is diagnosed based on characteristic cholangiographic patterns with multifocal strictures and intervening segments of normal or dilated ducts, when secondary causes of sclerosing cholangitis have been excluded. The pathogenesis of PSC is elusive, and there is currently no causal therapeutic strategy. Ursodeoxycholic acid may be beneficial for a subgroup of PSC patients, and new innovative therapeutics are currently under evaluation in clinical trials. Endoscopic interventions are used and effective to dilate dominant bile duct strictures and useful to diagnose biliary malignancy. The only definitive therapy is liver transplantation. It offers excellent long-term outcome, when timing is right. However, in a subset of patients biliary strictures and also recurrent PSC can limit the posttransplant prognosis.     

Endoscopy in the management of primary sclerosing cholangitis

Primary sclerosing cholangitis (PSC) is a chronic, cholestatic liver condition characterized by progressive fibrosis and destruction of the intra-and extrahepatic biliary tree. PSC has a clear association with inflammatory bowel disease and is often progressive, leading to cirrhosis and end-stage liver failure. For many patients, liver transplantation offers the only hope of long-term survival. No effective medical treatment exists, and therapy is often aimed at treating complications of the disorder, including dominant biliary strictures, which may cause symptomatic jaundice, cholangitis, and pruritus. Studies on endoscopic therapy (eg, biliary dilation and/or stent insertion) have shown favorable results, although most studies have been small, retrospective, and uncontrolled. Up to 20% of patients with PSC develop cholangiocarcinoma; however, distinguishing between cholangiocarcinoma and benign strictures can be difficult. Ideally, randomized trials are required to determine the safest and most effective endoscopic management for symptomatic dominant strictures.     

Percutaneous Pancreatography for Treatment of Complicated Pancreatic Duct Strictures

Background: Percutaneous transhepatic cholangiography was developed over 30 years ago for the diagnosis of biliary disorders. It has become an accepted interventional technique for management of biliary tract diseases, especially in patients who have failed attempted endoscopic retrograde pancreatography or have altered anatomy that makes the biliary tree endoscopically inaccessible. The correlative procedure, which we term ‘percutaneous pancreatography’ (PP), has only been described once in the literature. Case Presentations: We report the outcome of 4 patients undergoing PP for management of difficult pancreatic duct strictures. In all patients, PP was used to provide access and therapy of otherwise endoscopically impassable pancreatic duct strictures. PP-guided pancreatic stent duct placement was performed and allowed for subsequent successful endoscopie management of complex, benign pancreatic duct obstructions. Conclusions: PP is a useful modality for management of otherwise endoscopically impassable pancreatic duct Strictures.     

Diagnosis of cholangiocarcinoma

Cholangiocarcinoma is suspected based on signs of biliary obstruction, abnormal liver function tests, elevated tumor markers (carbohydrate antigen 19-9 and carcinoembryonic antigen), and ultrasonography showing a bile stricture or a mass, especially in intrahepatic cholangiocarcinoma. Magnetic resonance imaging (MRI) or computed tomography (CT) is performed for the diagnosis and staging of cholangiocarcinomas. However, differentiation of an intraductal cholangiocarcinoma from a hypovascular metastasis is limited at imaging. Therefore, reasonable exclusion of an extrahepatic primary tumor should be performed. Differentiating between benign and malignant bile duct stricture is also difficult, except when metastases are observed. The sensitivity of fluorodeoxyglucose positron emission tomography is limited in small, infiltrative, and mucinous cholangiocarcinomas. When the diagnosis of a biliary stenosis remains indeterminate at MRI or CT, endoscopic imaging (endoscopic or intraductal ultrasound, cholangioscopy, or optical coherence tomography) and tissue sampling should be carried out. Tissue sampling has a high specificity for diagnosing malignant biliary strictures, but sensitivity is low. The diagnosis of cholangiocarcinoma is particularly challenging in patients with primary sclerosing cholangitis. These patients should be followed with yearly tumor markers, CT, or MRI. In the case of dominant stricture, histological or cytological confirmation of cholangiocarcinoma should be obtained. More studies are needed to compare the accuracy of the various imaging methods, especially the new intraductal methods, and the imaging features of malignancy should be standardized.     

Efficacy of s-type stents for the treatment of the main pancreatic duct stricture in patients with chronic pancreatitis

Objective. Stents have been used to relieve pancreatic duct stricture and upstream dilatation. However, many of these stents are straight-type stents originally manufactured for biliary use. A plastic stent that was developed for use in the pancreatic duct was used in this study and its usefulness investigated.

Material and methods. The stent (s-type stent: 10?Fr in diameter) has two alternate flexions and the shape resembles the tilde mark “～” in appearance. After obtaining informed consent, stents were placed in 20 patients with abdominal pain caused by chronic pancreatitis and stricture of the distal main pancreatic duct. The stents were removed according to the clinical manifestations and replaced with new ones if the stricture persisted.

Results. In total, 33 stents were placed in 20 patients. Pain relief was attained in 19 patients (95%). The stricture improved after one stenting in 8 patients (40%). Owing to persistent stricture, the stenting was repeated in 11 patients. The 50% stent indwelling period was 369.0 days. No proximal or distal migration of the stent occurred and there were no serious complications.

Conclusions. In view of its long durability as a stent and no migration, the s-stent is safe and useful for the management of pancreatic ductal strictures in patients with chronic pancreatitis.     

Digital cholangioscopy: the diagnostic yield and impact on management of patients with biliary stricture

Abstract:

Objectives: Biliary strictures frequently present a diagnostic challenge. The aim of this study was to evaluate the impact of digital single-operator cholangioscopy (DSOC) on subsequent treatment of patients with biliary stricture.

Methods: Consecutive patients undergoing DSOC for biliary stricture were enrolled. Gold standard for final diagnosis included histology from surgical resection. In patients without surgery, clinical evaluation methods and repeated imaging studies were used for comparison of DSOC findings and final diagnosis. Patients were followed-up prospectively focusing on subsequent treatment.

Results: Among 30 enrolled patients, final diagnosis was malignant in 13 (43%) and benign in 17 (57%). The sensitivity and specificity of visual impression in diagnosing malignant stricture were 100% (95% CI: 75???100) and 76% (95% CI: 50???93), respectively. The sensitivity and specificity for biopsy were 92% (95% CI: 62???100) and 100% (95% CI: 78???100), respectively. One (3%) case of complicating cholangitis with fatal outcome occurred. Final treatment included surgery in 7 (23%), endoscopy in 18 (60%) and chemotherapy in 3 (10%) of patients.

Conclusions: In this study, favorable operating characteristics of DSOC were confirmed. Absolute negative predictive value of visual impression provided reassurance to patients with benign strictures who avoided unnecessary surgery in 53%. One (3%) case of cholangitis with fatal outcome occurred.     

Endoscopic needle aspiration biopsy at ERCP in the diagnosis of biliary strictures.

We have developed a ball-tipped catheter with a retractable 22-gauge, 7-mm long needle to perform endoscopic needle aspiration (ENA) for cytology and compared this technique to brush cytology of malignant-appearing biliary strictures during ERCP. Of 31 patients, 26 had proven malignant strictures involving the common bile duct and 5 had benign lesions. All 31 patients had ENA and 29 were brushed. Positive ENAs were obtained in 16 of 26 patients (61.5%) and positive brushings in 2 of 24 (8.3%). With the addition of two suspicious ENAs for pancreatic adenocarcinoma, 73% of patients had positive or suspicious cytology for malignancy by combined ENA and brush with a specificity of 100%. Although ENA appeared to be more sensitive in diagnosing cholangiocarcinoma, it proved to be most effective in the diagnosis of pancreatic adenocarcinoma when compared with brush cytology. One patient with cholangiocarcinoma in our series was diagnosed by brush cytology only, with a negative ENA, supporting our recommendation of using both endoscopic brushings and ENA for cytology when evaluating biliary strictures.