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.
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 better.
Benign features include 2:
- tapered margins
Malignant features include:
- 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 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 etiology.
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)
- 1. Babu S, Smithson J. Bile duct stricture: benign or malignant? J R Soc Med. 2002;95 (6): 302-4. J R Soc Med (link) - Free text at pubmed - Pubmed citation
- 2. Choi SH, Han JK, Lee JM et-al. Differentiating malignant from benign common bile duct stricture with multiphasic helical CT. Radiology. 2005;236 (1): 178-83. doi:10.1148/radiol.2361040792 - Pubmed citation
- 3. Bonnel DH, Liguory CL, Lefebvre JF et-al. Placement of metallic stents for treatment of postoperative biliary strictures: long-term outcome in 25 patients. AJR Am J Roentgenol. 1997;169 (6): 1517-22. AJR Am J Roentgenol (abstract) - Pubmed citation