A Rare Diagnosis Made by Wire-Guide Assisted Endobiliary Forceps

Abstract

Introduction Accurate diagnosis of indeterminate biliary strictures are challenging, oftentimes requiring a multidisciplinary approach and subjecting patients to repeat procedures. While the majority of indeterminate strictures are malignant, the surgical literature estimates that nearly a quarter of patients undergoing surgical resection for suspected biliary malignancy have benign etiology. Here, we present a case of a rare biliary neoplasm diagnosed by wire-guide assisted endobiliary forceps. Case Presentation A 72-year old male was referred to our department for new onset jaundice, pruritus, and decreased appetite. Laboratory evaluation was consistent with cholestatic jaundice (AST/ALT 144/164, alk phos 515, tbili 25). Imaging demonstrated intra-hepatic and proximal common bile duct dilation with an abrupt transition point causing near complete obliteration of the intrapancreatic portion of the common bile duct. The patient underwent an ERCP demonstrating a 12 mm stricture with proximal dilation. A biliary sphincterotomy was effected and brushings obtained for cytology. A fully covered metal stent was placed to allow for decompression. The bile duct cytology was negative for malignancy, demonstrating abundant bile duct epithelium with reactive cellular changes. A repeat ERCP was then performed approximately 2 weeks later. Repeat ERCP performed again demonstrated the common bile duct stricture (Fig 1). Wire-guide assisted biopsy forceps were were used to obtained multiple biopsies from the stricture (Fig 2). Pathology demonstrated a low-grade biliary intraductal papillary neoplasm (Fig 3). The patient has done well thus far and is scheduled to undergo a Whipple procedure in the coming weeks.1409_A.tif Figure 1: Bile duct stricture1409_B.tif Figure 2: Wire-guide assisted endobiliary forceps biopsy sampling1409_C.tif Figure 3: Fragmented papillary neoplasm with intestinal features (low grade)Discussion Biliary intraductal mucinous neoplasm (B-IPMN) is an uncommon entity characterized by papillary growth within the bile duct lumen. It is thought to in some ways resemble pancreatic IPMNs (P-IPMN); both are mucin producing tumors arising from epithelial cells having papillary growth pattern. There are clinicopathological differences between the two entities, suggesting that they are a result of two distinct underlying biological pathways. These differences may account for the higher propensity of B-IPMNs to undergo malignant transformation compared to P-IPMNs. Thus, early diagnosis is pivotal as surgical resection can be curative. This case describes a new technique which can be used to make such a rare diagnosis.