The role of endoscopic ultrasound and contrast-enhanced endoscopy ultrasound in a case of cholangiocarcinoma

Excerpt

There are several imaging methods available for the diagnosis of cholangiocarcinoma (CCA). Although magnetic resonance imaging (MRI) and endoscopic retrograde cholangiopancreatography (ERCP) are the primary methods for evaluating biliary strictures, endoscopic ultrasound (EUS) and contrast-enhanced endoscopy ultrasound (CEUS) have an important role, particularly when other methods are inconclusive [1]. A 69-year-old male presented with non-painful jaundice and weight loss and was referred to our unit to perform EUS. He was icteric and the abdomen was tender. Laboratory investigations showed an elevation of total bilirubin (3.4 mg/dL). Abdominal ultrasound revealed dilation of the common bile duct (CBD). Radial EUS revealed a dilated CBD (14 mm) with a distal irregular “shouldering” stenosis (Fig. 1). CEUS confirmed enhancement of the stricture, suggesting a distal CCA; a plastic stent (10 Fr, 5 cm) was placed and brush cytology was performed during ERCP. Three months later, the patient was again referred to us for EUS with fine needle aspiration (FNA) (EUS—FNA). He was icteric (total bilirubin 5.6 mg/dL). We were informed that an MRI had been performed and the findings were not considered specific enough to suggest a distal CCA; brush cytology was negative for neoplastic cells and the patient remained on follow up. The second EUS (linear) showed a “shouldering” stenosis and dilation of the CBD; EUS-FNA (25 G needle) collected cytological material. The plastic biliary stent was replaced by ERCP. The histologic analysis of the material collected during EUS-FNA revealed the presence of neoplastic cells, compatible with distal CCA (Fig. 2). The patient was referred for surgical resection.

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