Hilar Biliary Strictures

Abstract

Hilar biliary strictures present a unique challenge to endoscopists because of the difficulty in securing a diagnosis for the stricture and providing adequate therapeutic drainage. Hilar strictures can be secondary to underlying liver disease, such as primary sclerosing cholangitis (PSC), or postsurgical complications. However, the majority of hilar strictures are concerning for underlying malignancy such as cholangiocarcinoma. The challenge in diagnosing cholangiocarcinoma lies in part due to its desmoplastic character and tropism for bile such that it extends along the duct rather than grow intraluminally. Endoscopic retrograde cholangiopancreatography (ERCP) plays a critical role in the diagnosis of hilar strictures through the use of cytology brushings, biopsy forceps, and cholangioscopy and may require several procedures to secure a diagnosis. Therapeutic management of these strictures is also complex since endoscopists have to decide between unilateral versus bilateral biliary drainage, plastic or self-expandable metal stent (SEMS) placement, and, if bilateral SEMS is pursued, the ideal configuration for the SEMS. The goal of this chapter is to help present current data and our own personal approach to the diagnosis and therapeutic management of hilar strictures.