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Bile duct stricture

Dr Yuranga Weerakkody and Dr Frank Gaillard et al.

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

Aetiology

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

malignant
- cholangiocarcinoma
- involvement by pancreatic head adenocarcinoma
- involvement by ampulla of Vater adenocarcinoma
benign
- iatrogenic strictures
  - diathermy burns
  - haemostasis clips
  - suture granuloma
  - amputation neuroma of the cystic duct
  - previous anastomosis (e.g. post liver transplant)
- primary sclerosing cholangitis
- Mirizzi syndrome
- chronic pancreatitis
- previous stone passage

Although identification of malignant cells on washings obtained during ERCP can make the diagnosis, there are negative in 25 - 50% of cases ¹. Carcinoembryonic antigen (CEA) and CA 19-9 are sometimes expressed by cholangiocarcinomas. Careful imaging is therefore often required.

Radiographic features

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

morphology of the stricture
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 ideal.

Stricture morphology

Benign features include ²:

long segment
smooth
tapered margins

Malignant features include:

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

It is however 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)