Bile duct strictures are problematic in terms of management and distinction between benign and malignant.
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Pathology
Etiology
There are numerous causes of biliary duct strictures, including 1,2:
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malignant
involvement by pancreatic head adenocarcinoma
involvement by ampulla of Vater adenocarcinoma
involvement by gallbladder carcinoma 4
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benign
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iatrogenic strictures
diathermy burns
hemostasis clips
previous anastomosis (e.g. post liver transplant)
previous stone passage
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Although identifying 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 secreted by cholangiocarcinomas.
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 intravenous cholangiograms) 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.
Artefactual narrowing and pseudo-stricture of the extrahepatic bile duct can be caused by pulsatile vascular compression of the hepatic and gastroduodenal arteries, and it should not be misdiagnosed as a bile duct stricture, tumor or stone 6,7.
Associated findings
Associated findings include:
features of chronic pancreatitis
evidence of previous cholecystectomy
lymph node enlargement
infiltrating mass
Treatment and prognosis
Treatment and prognosis clearly depend on the underlying etiology.
For benign stricture, a number of treatment options exist, including:
cholangioplasty: percutaneous or retrograde balloon dilation 3
stent placement: only considered in failed cholangioplasty when 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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