Benign gastric ulcers: diagnosis and follow-up with double-contrast radiography

Double-contrast upper gastrointestinal examinations revealed 108 gastric ulcers at the authors' hospital during a recent 1-year period. With use of current double-contrast examination criteria for differentiating benign and malignant ulcers, the radiographic appearance was unequivocally benign in 68 patients, probably benign in 25, probably malignant in 12, and unequivocally malignant in three. Fifty-six patients with benign, probably benign, or probably malignant ulcers underwent endoscopy and biopsy. All 56 had benign ulcers. Another three patients with unequivocally malignant ulcers had endoscopically proved carcinomas. Thus, most suspicious ulcers were benign, but no benign-appearing ulcers were malignant. Follow-up double-contrast studies for 87 ulcers revealed complete ulcer healing in 68 (78%). A residual ulcer scar was observed in 61 of those 68 cases (90%). This experience suggests that double-contrast radiography is a valuable technique for diagnosing benign gastric ulcers and that once diagnosed, typically benign ulcers can be followed up radiographically until completely healed, without need for endoscopic intervention.     

Idiopathic eosinophilic esophagitis in adults: the ringed esophagus

PURPOSE: To retrospectively assess the findings of idiopathic eosinophilic esophagitis (IEE) at barium studies and determine the frequency of the ringed esophagus in patients with this condition. MATERIALS AND METHODS: The institutional review board approved all aspects of this retrospective study and did not require informed consent from patients whose records were included in the study. The study was compliant with the Health Insurance Portability and Accountability Act. A review of the pathology and radiology databases at the authors' institution revealed 14 patients (11 men and three women; mean age, 41.3 years) with IEE (defined as more than 20 eosinophils per high-power field in biopsy specimens) who had undergone barium studies and endoscopy. The radiographs were reviewed for strictures, esophagitis, or other abnormalities. The endoscopic reports, clinical records, and laboratory data were also reviewed and compared with the radiographic findings. RESULTS: Seven of the 14 patients (50%) had a history of allergies, and two of nine patients with complete blood cell counts (22%) had peripheral eosinophilia. Thirteen patients (93%) had dysphagia, six (43%) had food impactions, and six (43%) had reflux symptoms. Ten patients (71%) had a total of 11 strictures at barium studies (two in the upper part of the esophagus, two in the middle part, three in the distal part, one in the middle and distal parts, and three at the gastroesophageal junction). The strictures had a mean length of 5.1 cm. In seven patients (50%), the strictures contained multiple fixed ringlike indentations that produced a ringed esophagus. The ringlike indentations appeared as multiple, fixed, closely spaced, concentric rings traversing the stricture. Four patients (28%) had esophagitis. Of 13 patients who underwent recumbent imaging, 10 (77%) had hiatal hernias and nine (69%) had reflux. Eight of the 10 patients (80%) with strictures underwent endoscopic dilation procedures, which resulted in only temporary relief of dysphagia. CONCLUSION: The findings suggest that most patients with IEE have esophageal strictures, often with distinctive ringlike indentations that produce a ringed esophagus.     

Use of barium in evaluation of disorders of the upper gastrointestinal tract: current status

Biphasic contrast studies are generally advocated as the best current barium examination for the upper GI tract. Two recent prospective blinded trials compared the diagnostic results of a biphasic contrast examination--employing a medium-density barium suspension and glucagon--and endoscopy. Both methods appear to have nearly equal merit for the detection of peptic ulcer and gastric carcinoma. One of the trials demonstrated a relative inability of the barium examination to depict reflux esophagitis other than the severe variety, an inability that had been previously recognized. Earlier Japanese studies showed excellent results from biphasic studies in the detection of early and advanced gastric carcinoma. Because gastric carcinoma may present as a wide variety of lesions, ranging from minute alterations in mucosal relief through ulcers to masses, the values from these Japanese studies also test the sensitivity and specificity of the radiographic examination in demonstrating non-neoplastic lesions of the stomach. Ample data have shown that a radiographic examination compares favorably with endoscopy in the detection of esophageal carcinoma. The usefulness of a radiographic examination as a primary examination if disturbances of esophageal motor function are suspected is generally recognized. A state-of-the-art radiographic examination (ie, a biphasic examination, preferably with drug-induced hypotony) therefore appears to represent an appropriate initial examination in evaluation of most disorders of the upper GI tract. If this examination prompts the slightest suspicion of a malignant tumor, endoscopy should follow for the purpose of obtaining biopsy specimens. Endoscopy is not necessary if duodenal ulcers have been diagnosed by means of radiography; in typically benign gastric ulcers, radiographic follow-up without endoscopy may safely be considered. If in elderly patients multiple small gastric polyps have been detected, endoscopy is not needed. If complaints persist after negative results at radiographic examination, however, endoscopic intervention must be considered. If the complaints suggest reflux esophagitis, the clinician can choose between treatment and endoscopy. In a patient with acute upper GI bleeding, primary endoscopy may be preferred. This diagnostic approach in which endoscopy is employed as complementary to the barium examination is in most parts of the world a cost-effective one. It is also the safest possible option; although endoscopic complications are rare, their absolute number cannot be ignored if every patient had to undergo endoscopy. A biphasic approach with a medium-density barium suspension can be attempted in nearly every patient; if the patient proves unable to cooperate for an optimal double-contrast examination, a single-contrast examination can be performed with the same barium swallowed.     

Relationship between diffuse esophageal spasm and lower esophageal sphincter dysfunction on barium studies and manometry in 14 patients

OBJECTIVE: We sought to reassess the function and clinical characteristics of the lower esophageal sphincter in a series of patients with radiographically defined diffuse esophageal spasm. MATERIALS AND METHODS: In reviewing records in the radiology database at our hospital, we identified 14 patients with diffuse esophageal spasm confirmed on barium studies who also underwent esophageal manometry. The radiographic findings were reviewed and correlated with the manometric findings. Medical records were also reviewed to determine the clinical presentation, treatment, and patient course. RESULTS: All 14 patients were symptomatic, presenting with dysphagia, chest pain, or both. All the barium studies revealed intermittently absent or weakened peristalsis, with nonperistaltic contractions that were moderate in six patients (43%) and marked in eight patients (57%) (contractions nearly obliterating the lumen in six and completely obliterating the lumen in two). Nine patients (64%) had impaired opening of the lower esophageal sphincter, manifested by beaklike narrowing of the distal esophagus, and five (36%) had normal opening of the lower esophageal sphincter. Manometry revealed abnormal peristalsis in all 14 patients, with repetitive simultaneous contractions in eight (57%) and lower esophageal sphincter dysfunction in 12 (86%). All eight patients with lower esophageal sphincter dysfunction or incomplete relaxation of the lower esophageal sphincter on barium studies or manometry who were treated with the Clostridium botulinum toxin or endoscopic balloon dilatation had a positive response. CONCLUSION: Our preliminary data show that diffuse esophageal spasm is characterized on barium studies by frequent lower esophageal sphincter dysfunction rather than a classic corkscrew appearance. Barium and manometric studies may have complementary roles in the evaluation of patients with diffuse esophageal spasm.     

Esophageal lesions after total laryngectomy

Clinical and endoscopic evaluation of the post-total laryngectomy patient with dysphagia may be limited by postoperative fibrosis or strictures. The barium esophagogram is a valuable adjunctive tool in further assessing these patients, as both functional and anatomic abnormalities can be evaluated. A 10-year retrospective review yielded 204 patients who had had total laryngectomies for squamous cell carcinoma of the larynx; 85 of these patients had postoperative barium esophagograms. Dysphagia was the chief complaint in 73 of these 85 patients. The studies were reviewed for anatomic abnormalities of the surgically deformed pharynx (neopharynx) and the esophagus distal to it. While most patients (51%) with dysphagia had abnormalities in the neopharynx, 17 (23%) had abnormalities distal to the neopharynx; these included four esophageal carcinomas and 13 benign esophageal strictures. These results emphasize the importance of evaluating the entire esophagus and maintaining a high index of suspicion for distal esophageal disease in the total laryngectomy patient with dysphagia.     

Ileocecal valve: spectrum of normal findings at double-contrast barium enema examination

PURPOSE: To characterize the spectrum of normal findings of the ileocecal valve at double-contrast barium enema examination to allow differentiation between a normal valve and one infiltrated by tumor. MATERIALS AND METHODS: A search of radiology and endoscopy files showed 106 patients who underwent double-contrast barium enema examination and colonoscopy. The radiographic images were reviewed by two authors to determine the morphology of the ileocecal valve and to evaluate whether it appeared normal or abnormal. The radiographic data were then correlated with endoscopic and pathologic findings. RESULTS: The ileocecal valve was visible in 91 (86%) of 106 patients. It was round or ovoid in 71 patients (78%) and triangular in 20 (22%). In the 88 patients with a normal valve at colonoscopy, mean valve height was 1.7 cm, and mean width was 2.8 cm. The valve was smooth in 75 patients (85%) and smoothly lobulated in 13 (15%). The lips of the valve were symmetric in 77 patients (88%) and asymmetric in 11 (12%). All 87 patients with a normal valve at double-contrast barium enema examination had a normal valve at colonoscopy, whereas the two patients with a valve suspicious for tumor at barium enema examination had neoplasms (one carcinoma and one villous adenoma) at colonoscopy. CONCLUSION: The ileocecal valve may show a spectrum of normal findings at double-contrast barium enema examination and may appear as a round, ovoid, or triangular structure with a maximal height of nearly 4 cm. The valve may be large, asymmetric, or smoothly lobulated, even in the absence of tumor.     

Palliation of malignant esophageal strictures: initial results with self-expanding uncovered nitinol coil stents

The purpose of this study was to determine the efficacy of the uncovered coil stents in patients with malignant dysphagia. Coiled spring-shaped uncovered self-expanding metallic Esophacoil stents (Instent, Eden Prairie, Minnesota) were placed in 11 patients (9 men and 2 women; age range 38–77 years, mean age 60.5 years) with malignant esophageal strictures and dysphagia, under fluoroscopic guidance. Dysphagia was graded on a scale of 0 to 4 (0 = no dysphagia; 1 = dysphagia to normal solids; 2 = dysphagia to soft solids; 3 = dysphagia to solids and liquids; 4 = complete dysphagia, inability to swallow saliva). Two patients had received radiation therapy, 4 had had chemotherapy, and 5 had had a combination of both radiation and chemotherapy before stent palliation. Control clinical examinations and endoscopic or barium swallow studies were performed every 4 weeks until the patient died. The stents were well tolerated by all patients and were effective in 9 of 11 patients with malignant dysphagia. Complications of the procedure included incomplete opening of the stent in 1 case, migration in 1 case, transient pain in 8 cases, reflux in 3 cases and minor gastrointestinal bleeding in 2 cases. Stent migration in 1 case resulted in surgical intervention and incomplete opening of the stent allowed only partial improvement of dysphagia in 1 case. The quality of life significantly improved in all other patients. Mean survival time of the patients was 73 days (range 34–125 days) and no significant tumor ingrowth was detected during the follow-up period. Insertion of an Esophacoil has a good palliative effect on dysphagia in patients with malignant esophageal strictures with few complications. Although the stent is uncovered, tumor ingrowth and overgrowth were not observed in our study, possibly because of previous treatments. Received: 22 July 1998; Revision received: 30 November 1998; Accepted: 21 December 1998     

食管内支架置入后的随访研究

目的食管狭窄置入金属支架后长期随访，观察其疗效和并发症。方法４３例食管狭窄放置了金属支架患者有较完整的随访资料。良性狭窄１４例，恶性狭窄２９例。置入Ｕｌｔｒｅｆｌｅｘ支架３２例，ＧｉａｎｔｕｒｃｏＺ型带膜支架４例，国产网状支架６例，Ｗａｌｓｔｅｎｔ支架１例。门诊随访行食管造影和内窥镜检查２７例，电话或信访１６例。结果１～３２个月随访观察，无支架移位。２４例死亡，术后生存时间１７天至２８个月，平均６．８个月。死亡原因：肿瘤广泛转移１９例，肺部感染２例，其他原因引起死亡３例。发生再狭窄１６例，为支架内或两端发生狭窄。肿瘤组织生长造成的狭窄４例，１２例为食管腔内组织过度增生，这类狭窄全部发生在置入支架后４～５个月。支架内狭窄５例，支架两端狭窄１１例，其中１０例为支架上端狭窄。１２例行再次球囊扩张或支架置入。结论肿瘤的生长，特别是粘膜和纤维组织增生是引起再狭窄的主要原因，支架上端狭窄更容易发生吞咽困难。由于再狭窄的发生率较高，对于良性食管狭窄的支架成型术应严格选择病例。     

Radiological assessment of dysphagia with endoscopic correlation

Four hundred fifty consecutive patients with dysphagia were evaluated radiologically over a 14-month period; 127 of these (28.2%) were also examined endoscopically. The most common abnormality seen was dysmotility (34%), followed by hiatal hernia, benign stricture, and esophagitis. Correlation with endoscopy was generally good. Radiologic study demonstrated all cases of esophageal malignancy; radiologic/endoscopic correlation was also strong in patients with moderate or severe esophagitis, though the radiologist had some difficulty detecting mild inflammation. Endoscopy failed to demonstrate some benign strictures. Radiologic study was relatively accurate in detecting significant organic disease; most motility disorders were not detected by endoscopy. For these reasons, as well as lower cost, increased convenience, and patient comfort, radiologic assessment is recommended as the primary method of evaluating patients with dysphagia.     

Chronic ulcerative colitis and colon cancer: can radiographic appearance predict survival patterns?

Twenty-four patients with chronic ulcerative colitis and colon carcinoma who underwent barium enema examination prior to the diagnosis of cancer were studied in an attempt to correlate the radiographic appearance of the tumors with their biologic behavior, as well as to assess the accuracy of the barium enema in detection. Of the radiographically detected tumors, 65% displayed an annular infiltrative appearance, with the prime radiographic manifestation being relative nondistensibility of the involved segment. The remaining tumors had various appearances more typical of noncolitic colon cancer. Patients with infiltrative lesions had a much poorer prognosis than those with noninfiltrative lesions. Of 33 gross tumors described pathologically and/or surgically, only 70% were correctly detected by barium enema. It is suggested that periodic barium enema examinations are an unreliable means of following patients with ulcerative colitis if malignant degeneration is to be detected at an early and curative stage. Prophylactic proctocolectomy may be the best therapeutic approach.     

Nitinol Esophageal Stents: New Designs and Clinical Indications

Purpose To evaluate the clinical use of covered and noncovered, knitted nitinol stents in patients presenting new stent indications. Methods Self-expandable, knitted nitinol stents were implanted in four patients for treatment of dysphagia. In two patients who had malignant strictures and had esophago-respiratory fistulae and in one patient with an esophagocutaneous fistula, polytetrafluoroethylene (PTFE)-covered stents were implanted. One patient received a noncovered stent, but a retrograde approach through a percutaneous endoscopic gastrostomy (PEG) fistula had to be chosen for recanalization of an esophageal occulusion. Two patients received stents for treatment of benign strictures. Results Recanalization of the stricture and stent implantation were performed under fluoroscopic control without any procedure-related morbidity or mortality. Dysphagia improved in all patients and the esophageal fistulae could be sealed off by covered stents. During a maximum follow-up of 18 months, there was no stent migration or esophageal perforation. Complications observed were stent stenosis due to food impaction (1/4) and benign stent stenosis (2/2). Most complications could be treated by the interventional radiologist. Conclusion Self-expandable, covered Nitinol stents provide an option for the treatment of dysphagia combined with esophageal fistulae. In combination with interventional radiology techniques, even complex strictures are accessible. For benign strictures, the value of stent treatment has not yet been proven.     

Primary tumors of the patella

This study reports 42 cases of histologically proven and radiographically correlated primary patellar tumors. Despite diverse histologic diagnoses, the radiographic appearances of benign as opposed to malignant patellar neoplasms are essentially indistinguishable. Although the literature suggests that giant cell tumor is the most frequent benign tumor of the patella, the most common benign neoplasm in this series is chondroblastoma (16 cases). Only four primary malignant lesions were encountered, three cases of lymphoma and one case of hemangioendothelioma. Since 38 (90%) of the 42 cases were benign, a benign etiology should be strongly favored, notwithstanding the radiographic appearance, whenever a primary patellar tumor is encountered.The opinions or assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the Department of the Army or the Department of Defense.     

食管疾病的CT诊断（附30例分析）

３０例共３４次食管ＣＴ扫描，其中食管癌２３例，食管癌术后复发１例，食管静脉曲张和贲门失弛缓症各１例，钡餐疑食管外压性病变，经ＣＴ扫描，其中２例分别为右位主动脉和左主支气管压迫，另２例ＣＴ扫描无异常，经随访检查为正常。笔者分析了相应食管疾病的ＣＴ表现，重点讨论了食管癌的ＣＴ扫描方法及诊断，认为ＣＴ扫描是钡餐和胃镜检查的重要辅助方法，在良、恶性肿瘤的鉴别、判断有无转移及治疗方案的选择上有重要临床意义，并且可以随访观察疗效，指出食管癌管周脂肪间隙模糊或消失不宜作为能否手术切除的评价指标。     

Radiologically guided balloon dilation of gastrointestinal strictures. Part I. Technique and factors influencing procedural success

Radiologically guided balloon catheters were used to dilate 94 gastrointestinal strictures in 92 patients over a 6-year period. Fifty strictures were esophageal and 44 nonesophageal (22 gastroenterostomies, 11 antral-pyloric strictures, four colorectal strictures, four enteroenterostomies, and three miscellaneous strictures). Factors influencing the success of stricture intubation included patient age, stricture location (esophageal vs. nonesophageal and proximal vs. distal esophageal), and association with a surgical anastomosis. Malignancy was associated with greater postdilation irregularity and a smaller increase in stricture diameter, as measured radiographically. Procedural failures occurred in 8% of cases (2% of esophageal and 30% of nonesophageal lesions). Two small, asymptomatic mucosal tears were seen after dilation (one esophageal and one colonic); no other procedural complications occurred. Following successful dilation, 16 patients (17%; six with esophageal and ten with non-esophageal strictures) had recurrence of symptoms during short-term (30-day) follow-up.     

双球囊导管成形术治疗结直肠吻合口良性狭窄

目的评价透视下双球囊导管成形术治疗结直肠吻合口良性狭窄的疗效。方法17例结直肠吻合口良性狭窄的患者,在透视下行经肛门双球囊导管成形术。13例因恶性、4例因良性病变而接受结、直肠外科手术。16例因部分性梗阻表现为排便困难或排便次数增多,1例患者因溃疡性结肠炎,作全结肠切除术 临时性肠造瘘术后,其吻合口狭窄由内镜和钡灌肠检查发现并确定为良性。随访期观察疗效和并发症。结果17例患者在透视下进行了双球囊导管成形术1次。双球囊扩张成形术中,先用单球囊(直径为20mm)作为初步扩张,再附加第2枚球囊(直径为10、15或20mm)进行双球囊导管成形术。技术成功率为100%。球囊导管成形术后,症状完全改善12例(71%)、部分改善5例(29%)。未发生如肠破裂或严重出血等并发症。平均随访23个月(1～62个月),1例6个月后狭窄复发,给予再次双球囊导管成形术后,狭窄症状消失。结论透视下双球囊导管成形治疗良性结直肠吻合口狭窄安全可行。     

Strictures of the sigmoid colon: barium enema evaluation

PURPOSE: To assess the accuracy of radiologic interpretation, in the absence of clinical information, in the differentiation of benign and malignant sigmoid strictures at barium enema examination. MATERIALS AND METHODS: On two occasions, four independent observers retrospectively assessed examination findings in 78 patients with documented sigmoid strictures (43 benign, 35 malignant). Each stricture was graded by using a five-point scale (definitely malignant to definitely benign). RESULTS: No significant difference existed between the areas under the receiver operating characteristic curves for the two assessments with any observer. Consensus findings indicated agreement among at least three of the four observers in 68 (87%) and 66 (85%) cases at the first and second assessments, respectively. One benign stricture was called malignant at both assessments. When consensus existed, the positive predictive value for malignant strictures was 96% at both assessments (sensitivity, 63% and 66%). Nine malignant strictures were called benign, three at both assessments. When consensus existed, the positive predictive value for benign strictures was 84% and 88% at the first and second assessments, respectively (sensitivity, 88% and 86%, respectively). CONCLUSION: The differentiation between a benign and a malignant sigmoid stricture can be made in most cases at barium enema examination. When a stricture appears malignant, the diagnosis is usually correct, but caution is advised when a stricture appears benign.     

镍钛记忆合金食管内支架治疗食管疾病的临床研究

作者应用镍钛记忆合金食管内支架治疗各类食管疾病共９例，置入支加前吞咽困难Ｃｗｉｋｉｅｌ分级均达２－３组，置入后立即缓解，Ｃｗｉｋｉｅｌ０－１级者为１００％。全组病例除有异物感及轻微胸背疼痛外，无严重并发症发生。     

Intramural tracking: a feature of esophageal intramural pseudodiverticulosis

OBJECTIVE: Our purpose was to determine the frequency of intramural tracking in patients with esophageal intramural pseudodiverticulosis and to characterize the morphologic features of this finding on barium studies. MATERIALS AND METHODS: A review of radiology files at two institutions revealed 30 cases of esophageal intramural pseudodiverticulosis diagnosed at esophagography. In all cases, the radiographs were reviewed retrospectively to determine the frequency and morphologic features of intramural tracking in these patients. The number and distribution of pseudodiverticula and the presence or absence of strictures or esophagitis were also noted. RESULTS: Fifteen (50%) of 30 patients with esophageal intramural pseudodiverticulosis had intramural tracking on esophagography. The tracks had an average length of 1.2 cm (length range, 0.3-7 cm) and an average width of 1.6 mm (width range, 1-4 mm). The pseudodiverticula were more numerous and had a more diffuse distribution in patients with tracking than in patients without tracking. Although patients with and without tracking had a similar frequency of strictures and esophagitis, patients with tracking were more likely to have strictures involving the upper or mid esophagus, whereas patients without tracking were more likely to have strictures in the distal esophagus. These findings indicate that intramural tracking is more likely to occur in patients with the diffuse form of esophageal intramural pseudodiverticulosis. CONCLUSION: Intramural tracking was detected on esophagography in 50% of patients with esophageal intramural pseudodiverticulosis, so this type of tracking is a more common radiographic finding than has previously been recognized. Although intramural tracking has little or no known clinical significance, it is important to be aware of this finding so that it is not mistaken for a large flat ulcer in the esophagus or for an extramural collection associated with esophageal peridiverticulitis.     

Metallic stents for the treatment of biliary obstruction: A report of 100 cases

The results of the first 100 patients to receive Gianturco-Rösch “Z” stents is presented along with recommendations for their use. The patient population was comprised of 57 men and 43 women, age range 17–85 years (mean 65 years). Fifty-four of the patients had benign obstruction and 46 had malignant obstruction. Of the benign lesions, 11 had sclerosing cholangitis and the remainder had postoperative strictures. Thirty-one of the malignant obstructions were secondary to cholangiocarcinoma with the majority of the others secondary to metastases from various sources. All but one had multiple systems involved. Patients with benign postoperative strictures were all initially treated with balloon angioplasty; if this failed, stents were inserted. In patients who had stents in place for greater than 1 year, the occlusion rate was 13%. The overall occlusion rate in the 43 patients was 7%. Patients with sclerosing cholangitis did less well. In those with sclerosing cholangitis secondary to intraarterial chemotherapy, the occlusion rate was 77%, and we no longer use the metallic “Z” stent in these patients. The stent was not used for malignant common duct obstruction. All patients had hilar involvement. In the patients with malignant obstruction, 17% reobstructed prior to their death. The patients with cholangiocarcinoma did well with a mean survival time of 14 months and a re-obstruction rate of 16%. All late obstructions were secondary to tumor over-growth either proximal or distal to the stents. We conclude that the “Z” stent is an effective form of treatment in patients with benign postoperative strictures and those with malignant obstruction involving the hilum. We do not recommend it as a replacement for conventional stents, but rather as an additional device that allows treatment of some of the more difficult causes of obstruction.     

Differentiation of extrahepatic bile duct cholangiocarcinoma from benign stricture: findings at MRCP versus ERCP

PURPOSE: To retrospectively evaluate criteria for differentiating extrahepatic bile duct cholangiocarcinoma from benign cause of stricture at magnetic resonance cholangiopancreatography (MRCP) and to compare diagnostic accuracy with this modality versus endoscopic retrograde cholangiopancreatography (ERCP). MATERIALS AND METHODS: MRCP and ERCP images in 50 patients (27 with cholangiocarcinoma [18 men, nine women; mean age, 58 years] and 23 with benign cause of stricture [13 men, 10 women; mean age, 60 years]) were retrospectively reviewed to assess the appearance of bile duct strictures. Final diagnosis was based on surgical or biopsy findings. Strictures were described according to their imaging appearance (irregular or smooth margins, asymmetric or symmetric narrowing, abrupt narrowing or gradual tapering, and presence or absence of double-duct sign). Sensitivity, specificity, and accuracy of MRCP and ERCP were calculated by using ratings of confidence in image-based diagnosis. Lengths of stricture were electronically measured and compared by using the Student t test. RESULTS: Among cholangiographic criteria for malignant biliary stricture, irregular margins and asymmetric narrowing were more common in cholangiocarcinomas (24 [89%] of 27 patients) than in benign strictures (six [26%] and eight [35%] of 23 patients, respectively). Sensitivity, specificity, and accuracy of the two methods for differentiation of malignant from benign causes of biliary stricture were 81% (22 of 27), 70% (16 of 23), and 76% (38 of 50), respectively, for MRCP and 74% (20 of 27), 70% (16 of 23), and 72% (36 of 50), respectively, for ERCP. Mean length (+/- standard deviation) of cholangiocarcinomas was 30.0 mm +/- 8.5, and that of benign strictures was 13.6 mm +/- 9.1 (P <.001). CONCLUSION: Accuracy of MRCP is comparable with that of ERCP. Regardless of modality, a lengthy segment of extrahepatic bile duct stricture with irregular margin and asymmetric narrowing suggests cholangiocarcinoma, and a short segment with regular margin and symmetric narrowing suggests benign cause.