Bile duct stricture

Bile duct strictures are problematic in terms of management and distinction between benign and malignant.

Pathology

Aetiology

There are numerous causes of biliary duct strictures, including 1,2 :

Although identification of malignant cells on washings obtained during ERCP can make the diagnosis, they are negative in 25-50% of cases 1. Careful imaging is therefore often required.

Carcinoembryonic antigen (CEA) and CA 19-9 are sometimes expressed by cholangiocarcinoma. 

Radiographic features

The distinction between malignant and benign structures relies on two aspects:

  1. morphology of the stricture
  2. associated findings, pointing to a cause

As far as assessing the morphology of the stricture, modalities that image the lumen (ERCP, MRCP, CT IVC) are best, whereas to assess for associated features US or CT/MRI are better.

Stricture morphology

Benign features include 2:

  • smooth
  • tapered margins

Malignant features include:

  • irregular
  • shouldered margins
  • thickened (>1.5 mm) and enhancing (on arterial and or portal venous phase) duct walls 2

It is often difficult to distinguish between malignant and benign strictures, especially if short 2.

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 aetiology.

For benign stricture and number of options exist, including:

  • cholangioplasty: percutaneous or retrograde balloon dilation 3
  • 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)

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