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  • Review Article
  • Published:

Evaluation of indeterminate biliary strictures

Nature Reviews Gastroenterology & Hepatology volume 13, pages 28–37 (2016)Cite this article

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An Erratum to this article was published on 02 November 2017

This article has been updated

Key Points

  • Biliary strictures often present a diagnostic challenge in differentiating benign from malignant causes

  • Pre-operative diagnostic testing including laboratory, imaging, and endoscopic modalities can establish a diagnosis in most patients, but indeterminate lesions still account for up to 20% of cases

  • Novel biomarkers and endoscopic techniques are increasingly improving the diagnostic yield and should reduce unnecessary surgeries on benign strictures

Abstract

Biliary strictures frequently present a diagnostic challenge during pre-operative evaluation to determine their benign or malignant nature. A variety of benign conditions, such as primary sclerosing cholangitis (PSC) and IgG4-related sclerosing cholangitis, frequently mimic malignancies. In addition, PSC and other chronic biliary diseases increase the risk of cholangiocarcinoma and so require ongoing vigilance. Although traditional methods of evaluation including imaging, detection of circulating tumour markers, and sampling by endoscopic ultrasound and endoscopic retrograde cholangiopancreatography have a high specificity, they suffer from low sensitivity. Currently, up to 20% of biliary strictures remain indeterminate after pre-operative evaluation and necessitate surgical intervention for a definitive diagnosis. The discovery of novel biomarkers, new imaging modalities and advanced endoscopic techniques suggests that a multimodality approach might lead to better diagnostic accuracy.

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Figure 1: IgG4-related sclerosing cholangitis presenting with a pancreatic mass and biliary stricture.
Figure 2: Primary sclerosing cholangitis presenting with a mass of the common bile duct.
Figure 3: Algorithm for the evaluation of a distal biliary stricture in the absence of an obvious cause.
Figure 4: Algorithm for the evaluation of a proximal biliary stricture or distal stricture with a non-diagnostic EUS.

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Change history

  • 02 November 2017

    In the version of this article originally published online and in print, the main text incorrectly specified endoscopic ultrasonography (EUS)-guided fine-needle aspiration (FNA) when referring to reference 104 and the potential for seeding of tumours, when the study discussed FNA in general. The sentences should have read: "Despite the potential benefits of EUS-guided FNA, concerns have been raised about FNA in general and potential seeding along the needle tract resulting in peritoneal metastases103. In a study of 16 patients who had an FNA before pre-liver-transplantation laparoscopic staging, five of six patients with a FNA demonstrating malignancy upon cytological examination had peritoneal metastases identified104." This error has been corrected in the HTML and PDF versions of the article.

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Acknowledgements

This work was supported by a grant from NIDDK (R21DK100897 to C.L.B.).

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Authors and Affiliations

  1. Division of Gastroenterology and Hepatology, School of Medicine, University of California Davis, 4150 V Street, PSSB 3500, Sacramento, 95817, CA, USA

    Christopher L. Bowlus

  2. Department of Pathology and Laboratory Medicine, School of Medicine, University of California Davis, 4150 V Street, PSSB 3500, Sacramento, 95817, CA, USA

    Kristin A. Olson

  3. Division of Rheumatology, Allergy and Clinical Immunology, School of Medicine, University of California Davis, 4150 V Street, PSSB 3500, Sacramento, 95817, CA, USA

    M. Eric Gershwin

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  1. Christopher L. Bowlus
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  2. Kristin A. Olson
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  3. M. Eric Gershwin
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Contributions

C.L.B researched the data and developed the content and writing. K.A.O. provided the histologic images and descriptions. All authors contributed equally to editing and reviewing of the article.

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Correspondence to Christopher L. Bowlus.

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Bowlus, C., Olson, K. & Gershwin, M. Evaluation of indeterminate biliary strictures. Nat Rev Gastroenterol Hepatol 13, 28–37 (2016). https://doi.org/10.1038/nrgastro.2015.182

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