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Bile duct stricture

Bile duct strictures are both 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, 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:

  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 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)

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