What is the initial approach to managing a patient with a biliary stricture?

Initial Approach to Biliary Strictures

The initial management of a patient with biliary stricture should involve a multidisciplinary diagnostic workup with detailed imaging followed by endoscopic evaluation, with specific management determined by stricture etiology, location, and severity. 1

Diagnostic Evaluation

• Initial assessment should include detailed radiological evaluation with transabdominal ultrasound, multi-detector computed tomography (CT), and magnetic resonance imaging (MRI) with magnetic resonance cholangiopancreatography (MRCP) to detect and characterize biliary strictures 1
• Endoscopic ultrasound (EUS) provides more detailed examination of the extrahepatic biliary tree, pancreatic parenchyma, and ampullary region, with a sensitivity of 78% and specificity of 84% for diagnosing malignant biliary strictures 1
• Cross-sectional imaging studies should be performed before approaching endoscopic tissue acquisition to determine the location of the lesion and guide selection of appropriate diagnostic tools 2

Classification and Etiology Assessment

• Biliary strictures are classified by etiology (benign vs. malignant) and location (hilar, extrahepatic, intrahepatic) 1
• Benign causes include post-surgical/iatrogenic injury, primary sclerosing cholangitis (PSC), post-liver transplantation complications, chronic pancreatitis, and IgG4-related sclerosing cholangitis 1
• Malignant causes include cholangiocarcinoma, pancreatic adenocarcinoma, and metastatic disease 1
• The growth pattern of biliary malignancies affects the yield of tissue diagnosis - intraductal growth patterns are suitable for ERCP-guided transpapillary brushing or biopsy, while subepithelial lesions with outside growth may require different approaches 2

Initial Endoscopic Management

• For lesions causing outside compression of the biliary tree (e.g., pancreatic mass or lymphadenopathy), EUS-guided tissue acquisition should be the first priority 2
• For lesions within or invading the bile duct, intraductal biliary brushing or forceps biopsy is appropriate, especially when endoscopic biliary drainage is required 2
• ERCP with standard brushing and forceps biopsy is recommended as the first-line approach for tissue acquisition, with a sensitivity for malignancy of 45-70% 1
• Brush cytology and/or endoscopic biopsy should be performed to exclude superimposed malignancy prior to endoscopic therapy for dominant strictures 2

Management of Dominant Strictures

• In patients with increases in serum bilirubin, worsening pruritus, progressive bile duct dilatation on imaging studies, and/or cholangitis, ERCP should be performed promptly to exclude a dominant stricture 2
• Initial management of dominant strictures should involve endoscopic dilatation with or without stenting 2
• If an endoscopic approach is unsuccessful, biliary tract dilatation by percutaneous cholangiography with or without stenting should be considered 2
• For patients with surgically altered gastrointestinal anatomy, failed ERCP, or existing percutaneous transhepatic bile duct drainage, percutaneous transhepatic cholangioscopy-guided biopsy can be performed for tissue diagnosis 2

Advanced Diagnostic Modalities for Indeterminate Strictures

• For indeterminate biliary strictures, cholangioscopy-guided biopsies should be used in addition to standard ERCP diagnostic modalities 3
• Other advanced diagnostic modalities include intraductal ultrasound, probe-based confocal laser endomicroscopy, and fluoroscopy-guided probe-based confocal laser endomicroscopy 2, 1
• If available, cholangioscopy or fluoroscopy-guided probe-based confocal laser endomicroscopy can be added as complementary tests before tissue sampling for virtual diagnosis and for directing targeted biopsy 2

Management of Complications

• Antimicrobial therapy with correction of bile duct obstruction in dominant strictures is recommended to effectively resolve cholangitis 2
• For patients with recurrent bacterial cholangitis, prophylactic long-term antibiotics are recommended 2
• For refractory bacterial cholangitis, evaluation for liver transplantation should be considered 2
• Rates of ERCP-related adverse events are higher among PSC patients than non-PSC patients (7-18% vs. 3-11%) 2

Surgical Management

• In patients with dominant strictures refractory to endoscopic and/or percutaneous management, surgical therapy should be considered in selected patients without cirrhosis 2
• Surgical repair is recommended for major bile duct injuries with complete loss of continuity, with early aggressive surgical repair providing better results and avoiding sepsis 1
• Roux-en-Y biliary enteric diversion procedures have shown good long-term success rates for benign biliary strictures 4

Special Considerations for Primary Sclerosing Cholangitis (PSC)

• Endoscopic treatment of dominant strictures in PSC is recommended to improve liver biochemistry and pruritus 1
• Balloon dilatation with or without stenting is valuable for symptomatic dominant strictures in PSC 1
• Liver transplantation is the only curative therapy for late-stage PSC 1

Pitfalls and Caveats

• EUS-guided tissue acquisition of a primary biliary tumor should be approached with caution as it may eliminate the patient's opportunity for some potential interventions such as liver transplantation 2
• The complexity in selecting a tissue diagnostic tool should be emphasized, as it depends on the location of the lesion, different clinical settings, availability of expertise, cost, and endoscopist's personal preference 2
• Many repair failures of bile duct injuries are due to failure to follow fundamental principles, such as performing surgery on ischemic bile ducts 5