Still elusive: Developments in the accurate diagnosis of indeterminate biliary strictures

Indeterminate biliary strictures pose a significant diagnostic dilemma for gastroenterologists.Despite advances in endoscopic techniques and instruments,it is difficult to differentiate between benign and malignant pathology.A positive histological diagnosis is always preferred prior to high risk hepatobiliary surgery,or to inform other types of therapy.Endoscopic retrograde cholangiopancreato-graphy with brushings has low sensitivity and despite significant improvements in instruments there is still an unacceptably high false negative rate.Other methods such as endoscopic ultrasound and cholangioscopy have improved diagnostic quality.In this review we explore the techniques available to aid accurate diagnosis of indeterminate biliary strictures and obtain accurate histology to facilitate clinical management.

Clinical approach to indeterminate biliary strictures:Clinical presentation,diagnosis,and workup

Despite advances in cross-sectional imaging and endoscopic technology,bile duct strictures remain a challenging clinical entity.It is crucial to make an early determination of benign or malignant nature of biliary strictures.Early diagnosis not only helps with further management but also minimizes mortality and morbidity associated with delayed diagnosis.Conventional imaging and endoscopic techniques,particularly endoscopic retrograde cholangiopancreatography(ERCP)and tissue sampling techniques play a key in establishing a diagnosis.Indeterminate biliary strictures(IDBSs)have no definite mass on imaging or absolute histopathological diagnosis and often warrant utilization of multiple diagnostics to ascertain an etiology.In this review,we discuss possible etiologies,clinical presentation,diagnosis,and management of IDBSs.Based on available data and expert opinion,we depict an evidence based diagnostic algorithm for management of IDBSs.Areas of focus include use of traditional tissue sampling techniques such as ERCP with brush cytology,intraductal biopsies,fluorescence in situ hybridization and flow cytometry.We also describe the role of endoscopic ultrasound(EUS)-guided fine needle aspiration and biopsies,cholangioscopy,confocal laser endomicroscopy,and intraductal EUS in management of IDBSs.

Cholangioscopy-assisted guidewire placement in a malignant biliary stricture: A case report

BACKGROUND Cholangioscopy has been described in case reports and series to facilitate guidewire placement in difficult benign biliary strictures.Specifically,it has been infrequently used in difficult benign anastomotic liver transplant biliary strictures to visualize the stricture orifice for guidewire placement.Here we describe a case of guidewire placement through a difficult malignant biliary stricture using single operator cholangioscopy.CASE SUMMARY A 74-year-old female presented with jaundice and weight loss.Endoscopic ultrasound and endoscopic retrograde cholangiopancreatography(ERCP)by other endoscopists demonstrated pancreatic adenocarcinoma with a dilated cystic duct(CD)and proximal common bile duct(CBD).The associated distal CBD stricture was dilated and stented with a plastic stent.However she subsequently developed cholangitis,prompting referral for a repeat ERCP.The stent was found to have migrated distally to the confluence of the dilated CD and CBD stricture.Despite using multiple hydrophilic guidewires,the stricture could not be traversed due to preferential wire passage into the dilated CD.SpyGlass DS(Boston Scientific Corp,Marlborough,MA,United States)was then used to visualize the orifices of the CD and CBD stenosis,enabling the guidewire to be placed directly through the stricture into the proximal CBD.A WallFlex covered metal stent(Boston Scientific Corp,Marlborough,MA,United States)was successfully placed,resulting in resolution of her cholangitis.CONCLUSION To our knowledge,this is one of the first cases to describe successful cholangioscopic guidewire placement for malignant biliary strictures.

Endoscopic retrograde cholangiopancreatography guided interventions in the management of pancreatic cancer

Pancreatic cancer is the leading cause of cancer-related morbidity and mortality with an overall five-year survival of less than 9%in the United States.At presentation,the majority of patients have painless jaundice,pruritis,and malaise,a triad that develops secondary to obstruction,which often occurs late in the course of the disease process.The technical advancements in radiological imaging and endoscopic interventions have played a crucial role in the diagnosis,staging,and management of patients with pancreatic cancer.Endoscopic retrograde cholangiopancreatography(ERCP)-guided diagnosis(with brush cytology,serial pancreatic juice aspiration cytologic examination technique,or biliary biopsy)and therapeutic interventions such as pancreatobiliary decompression,intraductal and relief of gastric outlet obstruction play a pivotal role in the management of advanced pancreatic cancer and are increasingly used due to improved morbidity and complication rates compared to surgical management.In this review,we highlight various ERCP-guided diagnostic and therapeutic interventions for the management of pancreatic cancer.

Evaluation of Intraductal Ultrasonography, Endoscopic Brush Cytology and K-ras, P53 Gene Mutation in the Early Diagnosis of Malignant Bile Duct Stricture

Background： In qualitative diagnosis of bile duct stenosis, single diagnostic measure is difficult to make a correct diagnosis, to combine several diagnostic techniques may be helpful to make an accurate diagnosis. The aim of this study was to evaluate the value of intraductal ultrasonography （IDUS）, endoscopic brush cytology and K-ras, P53 gene mutation in the early diagnosis of malignant biliary stricture. Methods： From February 2012 to February 2013, 84 patients with suspected malignant biliary stricture were performed I DUS firstly, then endoscopic brush cytology and finally K-ras, P53 gene mutation detection, the sensitivity, specificity, positive predictive value, negative predictive value and accuracy of all above ways were evaluated and compared. Results： Of 84 patients, 52 cases were ultimately diagnosed malignant biliary stenosis; of which, 9 cases had no recurrence or metastasis to other organs after radical operation during the follow-up period. IDUS combined with brush cytology and K-ras ＋ P53 gene mutation detection had obvious advantage in the sensitivity, accuracy and negative predictive value than any other joint detection and single detection （the advantage was more significant compared with IDUS ＋ brush cytology or any single detection P 〈 0.01）. There were obvious statistical significance in the sensitivity and accuracy between IDUS ＋ brush cytology ＋ P53 or IDUS ＋ brush cytology ＋ K-ras and IDUS ＋ brush cytology or IDUS （P 〈 0.05）. There was no statistical significance in the sensitivity, specificity, positive predictive value, negative predictive value and accuracy between IDUS ＋ brush cytology ＋ P53 and IDUS ＋ brush cytology ＋ K-ras （P 〉 0.05）. Conclusions： IDUS combined with brush cytology and K-ras, P53 gene mutation detection is better than the separate detection and contribute to the early diagnosis of malignant biliary stricture. Its more widespread use is recommended.

Acute cholangitis with Achromobacter xylosoxidans bacteremia after endoscopic retrograde cholangiopancreatography in hilar cholangiocarcinoma:A case report

BACKGROUND Achromobacter xylosoxidans is a Gram-negative opportunistic aerobe,usually causing nosocomial infections in immunocompromised patients with manifestations including bacteremia,pneumonia,and catheter-related infections.However,A.xylosoxidans have not yet been reported to cause biliary system infections.CASE SUMMARY A 72-year-old woman presented to the outpatient department of our hospital with a chief complaint of jaundice.Computed tomography of her abdomen revealed the presence of a mass of approximately 2.4 cm in the hilar portion of the common hepatic duct,consistent with hilar cholangiocarcinoma.We performed endoscopic retrograde cholangiopancreatography(ERCP)to decompress the obstructed left and right intrahepatic ducts(IHDs)and placed 10 cm and 11 cm biliary stents in the left and right IHDs,respectively.However,the day after the procedure,the patient developed post-ERCP cholangitis as the length of the right IHD stent was insufficient for proper bile drainage.The blood culture of the patient tested positive for A.xylosoxidans.Management measures included the replacement of the right IHD stent(11 cm)with a longer one(12 cm)and administering culturedirected antibiotic therapy,solving the cholangitis-related complications.After the cholangitis had resolved,the patient underwent surgery for hilar cholangiocarcinoma and survived for 912 d without recurrence.CONCLUSION A.xylosoxidans-induced biliary system infections are extremely rare.Clinical awareness of physicians and endoscopists is required as this rare pathogen might cause infection after endoscopic procedures.