Bile duct stricture
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- updated 19 Aug 2022:
Nothing to disclose
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was changed:
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
involvement by pancreatic head adenocarcinoma
involvement by ampulla of Vater adenocarcinoma
involvement by gallbladder carcinoma 4
-
benign
-
iatrogenic strictures
diathermy burns
haemostasis clips
previous anastomosis (e.g. post liver transplant)
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 secreted by 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 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 exampleinclude:
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, a number of treatment options exist, including:
cholangioplasty: percutaneous or retrograde balloon dilation 3
stent placement: only considered in failed cholangioplasty
andwhen no other surgical optionssurgery with resection of the stenotic segment and re-anastomosis or choledochoenterostomy (e.g. Roux-en-Y)
-<p><strong>Bile duct strictures</strong> are problematic in terms of management and distinction between benign and malignant.</p><h4>Pathology</h4><h5>Aetiology</h5><p>There are numerous causes of biliary duct strictures, including <sup>1,2</sup>:</p><ul>-<li>-<strong>malignant </strong><ul>-<li><a href="/articles/cholangiocarcinoma">cholangiocarcinoma</a></li>-<li>involvement by <a href="/articles/pancreatic-ductal-adenocarcinoma-2">pancreatic head adenocarcinoma</a>-</li>-<li>involvement by <a href="/articles/ampulla-of-vater-adenocarcinoma">ampulla of Vater adenocarcinoma</a>-</li>-<li>involvement by <a href="/articles/gallbladder-carcinoma-1">gallbladder carcinoma</a><sup> 4</sup>-</li>-</ul>-</li>-<li>-<strong>benign</strong><ul>-<li>iatrogenic strictures<ul>-<li>diathermy burns</li>-<li>haemostasis clips</li>-<li><a href="/articles/suture-granuloma">suture granuloma</a></li>-<li><a href="/articles/amputation-neuroma-of-the-cystic-duct">amputation neuroma of the cystic duct</a></li>-<li>previous anastomosis (e.g. post liver transplant)</li>-</ul>-</li>-<li><a href="/cases/primary-sclerosing-cholangitis-psc-1">primary sclerosing cholangitis</a></li>-<li><a href="/articles/mirizzi-syndrome">Mirizzi syndrome</a></li>-<li><a href="/articles/chronic-pancreatitis-2">chronic pancreatitis</a></li>-<li>previous stone passage</li>-</ul>-</li>-</ul><p>Although identification of malignant cells on washings obtained during <a 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 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>-<li>morphology of the stricture</li>-<li>associated findings, pointing to a cause</li>-</ol><p>As far as assessing the morphology of the stricture, modalities that image the lumen (ERCP, <a href="/articles/magnetic-resonance-cholangiopancreatography-mrcp-2">MRCP</a>, <a 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>-<li>smooth</li>-<li>tapered margins</li>-</ul><p><strong>Malignant features include</strong>:</p><ul>-<li>irregular</li>-<li>shouldered margins</li>-<li>thickened (>1.5 mm) and enhancing (on arterial and or portal venous phase) duct walls <sup>2</sup>-</li>-</ul><p>It is often difficult to distinguish between malignant and benign strictures, especially if short <sup>2</sup>.</p><h5>Associated findings</h5><p>Associated findings are for example:</p><ul>-<li>features of chronic pancreatitis</li>-<li>evidence of previous cholecystectomy</li>-<li>lymph node enlargement</li>-<li>infiltrating mass</li>-</ul><h4>Treatment and prognosis</h4><p>Treatment and prognosis clearly depend on the underlying aetiology.</p><p>For benign stricture and number of options exist, including:</p><ul>-<li>cholangioplasty: percutaneous or retrograde balloon dilation <sup>3</sup>-</li>-<li>stent placement: only considered in failed cholangioplasty and no other surgical options</li>-<li>surgery with resection of the stenotic segment and re-anastomosis or choledochoenterostomy (e.g. Roux-en-Y)</li>- +<p><strong>Bile duct strictures</strong> are problematic in terms of management and distinction between benign and malignant.</p><h4>Pathology</h4><h5>Aetiology</h5><p>There are numerous causes of biliary duct strictures, including <sup>1,2</sup>:</p><ul>
- +<li>
- +<p><strong>malignant</strong></p>
- +<ul>
- +<li><p><a href="/articles/cholangiocarcinoma">cholangiocarcinoma</a></p></li>
- +<li><p>involvement by <a href="/articles/pancreatic-ductal-adenocarcinoma-4">pancreatic head adenocarcinoma</a></p></li>
- +<li><p>involvement by <a href="/articles/ampulla-of-vater-adenocarcinoma">ampulla of Vater adenocarcinoma</a></p></li>
- +<li><p>involvement by <a href="/articles/gallbladder-carcinoma-1">gallbladder carcinoma</a><sup> 4</sup></p></li>
- +</ul>
- +</li>
- +<li>
- +<p><strong>benign</strong></p>
- +<ul>
- +<li>
- +<p>iatrogenic strictures</p>
- +<ul>
- +<li><p>diathermy burns</p></li>
- +<li><p>haemostasis clips</p></li>
- +<li><p><a href="/articles/suture-granuloma">suture granuloma</a></p></li>
- +<li><p><a href="/articles/amputation-neuroma-of-the-cystic-duct">amputation neuroma of the cystic duct</a></p></li>
- +<li><p>previous anastomosis (e.g. post liver transplant)</p></li>
- +</ul>
- +</li>
- +<li><p><a href="/cases/primary-sclerosing-cholangitis-psc-1">primary sclerosing cholangitis</a></p></li>
- +<li><p><a href="/articles/mirizzi-syndrome">Mirizzi syndrome</a></p></li>
- +<li><p><a href="/articles/chronic-pancreatitis-2">chronic pancreatitis</a></p></li>
- +<li><p>previous stone passage</p></li>
- +</ul>
- +</li>
- +</ul><p>Although identification of malignant cells on washings obtained during <a 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 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>
- +<li><p>morphology of the stricture</p></li>
- +<li><p>associated findings, pointing to a cause</p></li>
- +</ol><p>As far as assessing the morphology of the stricture, modalities that image the lumen (ERCP, <a href="/articles/magnetic-resonance-cholangiopancreatography-mrcp-2">MRCP</a>, <a href="/articles/ct-cholangiography-protocol">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 </strong>include <sup>2</sup>:</p><ul>
- +<li><p>smooth</p></li>
- +<li><p>tapered margins</p></li>
- +</ul><p><strong>Malignant features </strong>include:</p><ul>
- +<li><p>irregular</p></li>
- +<li><p>shouldered margins</p></li>
- +<li><p>thickened (>1.5 mm) and enhancing (on arterial and or portal venous phase) duct walls <sup>2</sup></p></li>
- +</ul><p>It is often difficult to distinguish between malignant and benign strictures, especially if short <sup>2</sup>.</p><h5>Associated findings</h5><p>Associated findings include:</p><ul>
- +<li><p>features of chronic pancreatitis</p></li>
- +<li><p>evidence of previous cholecystectomy</p></li>
- +<li><p>lymph node enlargement</p></li>
- +<li><p>infiltrating mass</p></li>
- +</ul><h4>Treatment and prognosis</h4><p>Treatment and prognosis clearly depend on the underlying aetiology.</p><p>For benign stricture, a number of treatment options exist, including:</p><ul>
- +<li><p>cholangioplasty: percutaneous or retrograde balloon dilation <sup>3</sup></p></li>
- +<li><p>stent placement: only considered in failed cholangioplasty when no other surgical options</p></li>
- +<li><p>surgery with resection of the stenotic segment and re-anastomosis or choledochoenterostomy (e.g. Roux-en-Y)</p></li>
References changed:
- 1. Babu S & Smithson J. Bile Duct Stricture: Benign or Malignant? J R Soc Med. 2002;95(6):302-4. <a href="https://doi.org/10.1177/014107680209500612">doi:10.1177/014107680209500612</a> - <a href="https://www.ncbi.nlm.nih.gov/pubmed/12042380">Pubmed</a>
- 2. Choi S, Han J, Lee J et al. Differentiating Malignant from Benign Common Bile Duct Stricture with Multiphasic Helical CT. Radiology. 2005;236(1):178-83. <a href="https://doi.org/10.1148/radiol.2361040792">doi:10.1148/radiol.2361040792</a> - <a href="https://www.ncbi.nlm.nih.gov/pubmed/15955859">Pubmed</a>
- 3. Bonnel D, Liguory C, Lefebvre J, Cornud F. Placement of Metallic Stents for Treatment of Postoperative Biliary Strictures: Long-Term Outcome in 25 Patients. AJR Am J Roentgenol. 1997;169(6):1517-22. <a href="https://doi.org/10.2214/ajr.169.6.9393155">doi:10.2214/ajr.169.6.9393155</a> - <a href="https://www.ncbi.nlm.nih.gov/pubmed/9393155">Pubmed</a>
- 4. Katabathina V, Dasyam A, Dasyam N, Hosseinzadeh K. Adult Bile Duct Strictures: Role of MR Imaging and MR Cholangiopancreatography in Characterization. Radiographics. 2014;34(3):565-86. <a href="https://doi.org/10.1148/rg.343125211">doi:10.1148/rg.343125211</a> - <a href="https://www.ncbi.nlm.nih.gov/pubmed/24819781">Pubmed</a>
- 5. Shanbhogue A, Tirumani S, Prasad S, Fasih N, McInnes M. Benign Biliary Strictures: A Current Comprehensive Clinical and Imaging Review. AJR Am J Roentgenol. 2011;197(2):W295-306. <a href="https://doi.org/10.2214/AJR.10.6002">doi:10.2214/AJR.10.6002</a> - <a href="https://www.ncbi.nlm.nih.gov/pubmed/21785056">Pubmed</a>
- 1. Babu S, Smithson J. Bile duct stricture: benign or malignant? J R Soc Med. 2002;95 (6): 302-4. <a href=http://www.jrsm.org/cgi/pmidlookup?view=long&pmid=12042380">J R Soc Med (link)</a> - <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1279916">Free text at pubmed</a> - <a href="http://www.ncbi.nlm.nih.gov/pubmed/12042380">Pubmed citation</a><div class="ref_v2"></div>
- 2. Choi SH, Han JK, Lee JM et-al. Differentiating malignant from benign common bile duct stricture with multiphasic helical CT. Radiology. 2005;236 (1): 178-83. <a href=http://dx.doi.org/10.1148/radiol.2361040792">doi:10.1148/radiol.2361040792</a> - <a href="http://www.ncbi.nlm.nih.gov/pubmed/15955859">Pubmed citation</a><div class="ref_v2"></div>
- 3. Bonnel DH, Liguory CL, Lefebvre JF et-al. Placement of metallic stents for treatment of postoperative biliary strictures: long-term outcome in 25 patients. AJR Am J Roentgenol. 1997;169 (6): 1517-22. <a href=http://www.ajronline.org/cgi/content/abstract/169/6/1517">AJR Am J Roentgenol (abstract)</a> - <a href="http://www.ncbi.nlm.nih.gov/pubmed/9393155">Pubmed citation</a><div class="ref_v2"></div>
- 4. Venkata S. Katabathina, Anil K. et al. Adult Bile Duct Strictures: Role of MR Imaging and MR Cholangiopancreatography in Characterization. (2014) RadioGraphics. 34 (3): 565-86. <a href="https://doi.org/10.1148/rg.343125211">doi:10.1148/rg.343125211</a> - <a href="https://www.ncbi.nlm.nih.gov/pubmed/24819781">Pubmed</a> <span class="ref_v4"></span>
- 5. Shanbhogue A, Tirumani S, Prasad S, Fasih N, McInnes M. Benign Biliary Strictures: A Current Comprehensive Clinical and Imaging Review. AJR Am J Roentgenol. 2011;197(2):W295-306. <a href="https://doi.org/10.2214/ajr.10.6002">doi:10.2214/ajr.10.6002</a> - <a href="https://www.ncbi.nlm.nih.gov/pubmed/21785056">Pubmed</a>
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