Bile duct stricture

Last revised by Henry Knipe on 5 Dec 2023

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

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 secreted by cholangiocarcinomas. 

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 intravenous cholangiograms) are best, whereas to assess for associated features US or CT/MRI are better.

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 include:

  • features of chronic pancreatitis

  • evidence of previous cholecystectomy

  • lymph node enlargement

  • infiltrating mass

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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Cases and figures

  • Case 1: benign stricture
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  • Case 2: primary sclerosing cholangitis
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  • Case 3: post operative
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  • Case 4: lower CBD malignant stricture
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  • Case 5
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  • Case 6
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