Bile duct stricture

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Bile duct strictures are problematic in terms of management and distinction between benign and malignant.

Pathology

Aetiology

There are numerous causes of biliary duct strictures, including ^1,2:

malignant
- cholangiocarcinoma
- involvement by pancreatic head adenocarcinoma
- involvement by ampulla of Vater adenocarcinoma
- involvement by gallbladder carcinoma⁴
benign
- iatrogenic strictures
  - diathermy burns
  - haemostasis clips
  - suture granuloma
  - amputation neuroma of the cystic duct
  - previous anastomosis (e.g. post liver transplant)
- primary sclerosing cholangitis
- Mirizzi syndrome
- chronic pancreatitis
- previous stone passage

Although identification of malignant cells on washings obtained during ERCP can make the diagnosis, they are negative in 25-50% of cases ¹. Careful imaging is therefore often required.

Carcinoembryonic antigen (CEA) and CA 19-9 are sometimes ~~expressed~~secreted by ~~cholangiocarcinoma~~cholangiocarcinomas.

Radiographic features

The distinction between malignant and benign structures relies on two aspects:

morphology of the stricture
associated findings, pointing to a cause

As far as assessing the morphology of the stricture, modalities that image the lumen (ERCP, MRCP, CT ~~IVC~~intravenous cholangiograms) are best, whereas to assess for associated features US or CT/MRI are better.

Stricture morphology

Benign features include ²:

smooth
tapered margins

Malignant features include:

irregular
shouldered margins
thickened (>1.5 mm) and enhancing (on arterial and or portal venous phase) duct walls ²

It is often difficult to distinguish between malignant and benign strictures, especially if short ².

Associated findings

Associated findings are for example:

features of chronic pancreatitis
evidence of previous cholecystectomy
lymph node enlargement
infiltrating mass

Treatment and prognosis

Treatment and prognosis clearly depend on the underlying aetiology.

For benign stricture and number of options exist, including:

cholangioplasty: percutaneous or retrograde balloon dilation ³
stent placement: only considered in failed cholangioplasty and no other surgical options
surgery with resection of the stenotic segment and re-anastomosis or choledochoenterostomy (e.g. Roux-en-Y)

-</ul><p>Although identification of malignant cells on washings obtained during ERCP can make the diagnosis, they are negative in 25-50% of cases <sup>1</sup>. Careful imaging is therefore often required.</p><p><a href="/articles/carcinoembryonic-antigen">Carcinoembryonic antigen</a> (CEA) and <a href="/articles/ca-19-9">CA 19-9</a> are sometimes expressed by cholangiocarcinoma. </p><h4>Radiographic features</h4><p>The distinction between malignant and benign structures relies on two aspects:</p><ol>
+</ul><p>Although identification of malignant cells on washings obtained during <a title="ERCP" href="/articles/endoscopic-retrograde-cholangiopancreatography">ERCP</a> can make the diagnosis, they are negative in 25-50% of cases <sup>1</sup>. Careful imaging is therefore often required.</p><p><a title="Carcinoembryonic antigen (CEA)" href="/articles/cea">Carcinoembryonic antigen (CEA)</a> and <a href="/articles/ca-19-9">CA 19-9</a> are sometimes secreted by cholangiocarcinomas. </p><h4>Radiographic features</h4><p>The distinction between malignant and benign structures relies on two aspects:</p><ol>
-</ol><p>As far as assessing the morphology of the stricture, modalities that image the lumen (ERCP, MRCP, CT IVC) are best, whereas to assess for associated features US or CT/MRI are better.</p><h5>Stricture morphology</h5><p><strong>Benign features include</strong> <sup>2</sup>:</p><ul>
+</ol><p>As far as assessing the morphology of the stricture, modalities that image the lumen (ERCP, <a title="Magnetic resonance cholangiopancreatography (MRCP)" href="/articles/magnetic-resonance-cholangiopancreatography-mrcp-2">MRCP</a>, <a title="CT intravenous cholangiograms (CT IVC)" href="/articles/ct-cholangiography">CT intravenous cholangiograms</a>) are best, whereas to assess for associated features US or CT/MRI are better.</p><h5>Stricture morphology</h5><p><strong>Benign features include</strong> <sup>2</sup>:</p><ul>

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