Approach to Biliary Strictures

Initial Diagnostic Evaluation

The American Gastroenterological Association recommends a multidisciplinary diagnostic workup with detailed imaging followed by endoscopic evaluation for biliary strictures, with the specific management strategy determined by stricture etiology, location, and severity 1, 2
Detailed radiological evaluation is essential for detecting and characterizing biliary strictures and selecting appropriate tissue sampling techniques, including transabdominal ultrasound, multi-detector computed tomography (CT), and magnetic resonance imaging (MRI) with magnetic resonance cholangiopancreatography (MRCP) 1, 3
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

The American Association for the Study of Liver Diseases classifies biliary strictures by etiology, including benign causes such as post-surgical/iatrogenic, primary sclerosing cholangitis (PSC), post-liver transplantation, chronic pancreatitis, and IgG4-related sclerosing cholangitis, and malignant causes such as cholangiocarcinoma, pancreatic adenocarcinoma, and metastatic disease 3, 4, 5, 6
Biliary strictures can also be classified by location, including hilar strictures (Bismuth-Corlette classification), extrahepatic strictures, and intrahepatic strictures 1, 3

The European Society of Gastrointestinal Endoscopy recommends ERCP with standard brushing and forceps biopsy as the first-line approach for tissue acquisition, with a sensitivity for malignancy of 45-70% 1, 2
Advanced diagnostic modalities for indeterminate strictures include EUS-guided fine needle aspiration (FNA), single-operator cholangioscopy-guided biopsy, intraductal ultrasound, and probe-based confocal laser endomicroscopy 1, 7

The American College of Gastroenterology recommends endoscopic management as the first-line approach for benign biliary strictures, especially post-cholecystectomy, with temporary placement of multiple plastic stents or fully covered self-expanding metal stents (SEMS) 8
Percutaneous transhepatic biliary drainage (PTBD) is indicated when ERCP is unsuccessful or not feasible, or in septic patients with complete obstruction of the common bile duct 8, 5
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 8

The American Association for the Study of Liver Diseases recommends endoscopic treatment of dominant strictures in primary sclerosing cholangitis (PSC) to improve liver biochemistry and pruritus, with balloon dilatation with or without stenting being valuable for symptomatic dominant strictures 4, 6
Liver transplantation is the only curative therapy for late-stage PSC 4
Post-liver transplantation strictures can be anastomotic or non-anastomotic, with anastomotic strictures responding well to endoscopic or percutaneous treatment, and non-anastomotic strictures being more difficult to treat endoscopically 3, 5

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, according to the American Gastroenterological Association 9
For lesions causing outside compression of the biliary tree, EUS-guided tissue acquisition should be the first priority, as recommended by the American Gastroenterological Association 9
Brush cytology and/or endoscopic biopsy should be performed to exclude superimposed malignancy prior to endoscopic therapy for dominant strictures, as suggested by the American Association for the Study of Liver Diseases 10

Initial management of dominant strictures should involve endoscopic dilatation with or without stenting, as recommended by the American Association for the Study of Liver Diseases 10
Antimicrobial therapy with correction of bile duct obstruction in dominant strictures is recommended to effectively resolve cholangitis, according to the American Association for the Study of Liver Diseases 10

Rates of ERCP-related adverse events are higher among Primary Sclerosing Cholangitis patients than non-Primary Sclerosing Cholangitis patients (7-18% vs. 3-11%), as reported by the American College of Radiology 11
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, as noted by the American Gastroenterological Association 9