Bile duct stricture
Updates to Article Attributes
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 :
-
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
- iatrogenic strictures
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:
-
longshort segment - smooth
- tapered margins
Malignant features include:
-
shortlong 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)
-<li>long segment</li>- +<li>short segment</li>
-<li>short segment</li>- +<li>long segment</li>
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