Management of Dominant Strictures in Primary Sclerosing Cholangitis
Balloon dilation alone should be the first-line treatment for dominant strictures in PSC, with stenting reserved only for strictures that fail to respond adequately to balloon dilation. 1, 2
Initial Diagnostic Workup
Before any endoscopic intervention, patients require:
Non-invasive imaging with MRCP, dynamic liver MRI, and/or contrast CT when presenting with new or changing symptoms, worsening jaundice, increasing pruritus, or evolving laboratory abnormalities 1, 2
Multidisciplinary assessment before proceeding to ERCP, as patients should not undergo ERCP until expert hepatopancreaticobiliary team review justifies endoscopic intervention 1
Mandatory pathological sampling (brush cytology and/or biopsy) of any suspicious strictures during ERCP to exclude cholangiocarcinoma, which occurs in 26% of patients with dominant strictures 1, 3
This stepwise approach is critical because cholangiocarcinoma presents within 4 months of PSC diagnosis in half of affected patients, making thorough evaluation of new dominant strictures essential 3.
First-Line Treatment: Balloon Dilation
Balloon dilation without stenting is strongly preferred based on superior safety profile and equivalent efficacy 1, 2:
Technical Approach
Select balloon diameter of 6-8 mm for hepatic ducts and up to 8 mm for common bile duct, matching the caliber of ducts delimiting the stricture 2, 4
Perform stepwise dilation to avoid exceeding upstream/downstream duct diameter 4
Technical success is defined as complete balloon inflation with no waist on fluoroscopy plus unobstructed contrast passage 2, 4
Repeat dilations at 1-4 week intervals until technical success, typically requiring 2-3 sessions with success rates of 80-90% 2, 4
Evidence Supporting Balloon Dilation
The multicenter randomized DILSTENT trial (n=65) was prematurely stopped due to significantly higher serious adverse events in the stent group (45%) versus balloon dilation group (7%), with odds ratio of 11.7 (95% CI 2.4-57.2, P=0.001) 5, 2. The balloon dilation group experienced only 2 treatment-related serious adverse events compared to 15 in the stent group, with no difference in recurrence-free patency rates at 24 months 5.
Long-term data from 96 patients undergoing regular balloon dilations over median 7-year follow-up showed excellent safety with complication rates of 2.2% for pancreatitis, 1.4% for cholangitis, and 0.2% for bile duct perforation, with 5- and 10-year transplant-free survival rates of 81% and 52% respectively 1.
Second-Line Treatment: Stenting
Stenting should only be used when strictures fail to respond adequately to balloon dilation alone 1, 2, 4:
When to Consider Stenting
- Strictures that do not open satisfactorily with balloon dilation 1
- Refractory dominant strictures after multiple failed balloon dilation attempts 6
Stenting Approach
Short-term stenting (1-2 weeks maximum) is preferred over long-term stenting to reduce complications 2, 4
Single 10-Fr stent for extrahepatic dominant strictures 4
Two 7-Fr stents for hilar strictures extending into left or right hepatic duct 4
Remove stents after 1-2 weeks, as short-term stenting (mean 9 days) shows similar efficacy to standard 8-12 week stenting but with lower complication rates 1, 2, 4
Long-term stenting carries high rates of stent occlusion and/or cholangitis within 3 months of insertion 1. Short-term stenting improved jaundice and cholestasis symptoms in 81% versus 57% in historical controls undergoing 2-3 monthly elective stent changes 1, 7.
Prophylactic Measures
Administer prophylactic antibiotics before every ERCP due to high risk of cholangitis in PSC patients 2, 4. This is a strong recommendation based on high-quality evidence 2.
Role of Biliary Sphincterotomy
Biliary sphincterotomy should not be performed routinely but considered case-by-case 2:
- Particularly indicated after difficult cannulation in patients likely to require multiple ERCPs 2
- In PSC, sphincterotomy has been associated with increased risk of short-term adverse events, but may be protective for subsequent ERCPs 2
Follow-Up Strategy
Regular endoscopic follow-up at 3,6,12,18, and 24 months, then yearly 4:
- Repeat dilation for relapsing dominant strictures if the stricture causes recurrent symptoms or significant cholestasis increase and previous dilations showed satisfactory response 4
- Multiple dilations are usually required over months or years to maintain patency 1
Critical Pitfalls to Avoid
Do not use long-term stenting as first-line therapy - this approach requires repeated ERCPs for stent removal/replacement and carries 50% cholangitis rates versus 18% with balloon dilation alone 1.
Always exclude cholangiocarcinoma before treating dominant strictures - the 26% risk of cholangiocarcinoma in patients with dominant strictures mandates pathological sampling during ERCP 1, 3.
Avoid aggressive dilation beyond upstream/downstream duct diameter - bile duct perforation rates increase from 0.2% with standard balloon dilation to 3.5% with aggressive dilation 4.