Biliary Web: Diagnosis With High-Definition Videocholangioscopy

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A74-year-old obese woman presented to our center for evaluation of a persistent biliary stricture requiring intermittent stenting of the bile duct. A detailed history showed that she had undergone 15 to 20 endoscopic retrograde cholangiopancreatography (ERCP) examinations within the past 10 years for this problem. During most of these examinations, bile duct stones proximal to the stricture were found and removed. Brushings of the stricture had been negative for malignancy. Her last ERCP, 3 weeks before referral, again showed the presence of a stricture just proximal to the insertion of the cystic duct. At our center, she underwent an ERCP with peroral cholangioscopy. The ERCP confirmed the presence of the stricture. High-definition peroral videocholangioscopy (CHF-Y0002B; Olympus Corporation, Tokyo, Japan) showed a biliary web just proximal to the insertion of the cystic duct at the site of the presumed stricture (Figures A and B). Biliary webs are rare, with approximately 20 cases reported in the literature. The majority of biliary webs are associated with choledocholithiasis as a result of impaired biliary drainage. Although the exact mechanism behind formation of webs in the bile ducts is not known, at least some are believed to be congenital. During the development of the human embryo, the bile ducts pass through a solid stage, becoming obliterated by epithelial proliferation. Recanalization of the lumen of the biliary tree usually starts at the end of the fifth week of gestation. Incomplete recanalization could lead to web development. The diagnosis of biliary webs typically is made by contrast cholangiography or magnetic resonance imaging. Although radiographic images of biliary webs have been reported previously, direct in vivo cholangioscopic image of a biliary web has not been published. The patient was referred to surgery and underwent a successful choledochoduodenostomy. Pathology of the web showed fibrosis and chronic inflammation, which likely was caused by mechanical irritation by stones (Figure C). The patient has had more than a year of follow-up evaluation without any biliary problems.