Malignant Causes Of Biliary Obstruction Research Articles

A239 PATIENT OUTCOMES AFTER ENDOSCOPIC STENT INSERTION FOR MALIGNANT BILIARY OBSTRUCTION: A QUALITY ASSURANCE STUDY

Abstract Background Management of pancreaticobiliary malignancy is complex and multi-disciplinary. Decompression of malignant biliary obstruction (MBO) is preferentially achieved with endoscopic retrograde cholangiopancreatography (ERCP) and biliary stent placement. This may improve the quality of life for patients with unresectable disease and improve outcomes in resectable/borderline-resectable disease. Purpose To assess quality outcomes in patients undergoing biliary stenting for MBO. Method This is a retrospective chart audit of patients referred to the University of Alberta Hospital (UAH) for suspected or confirmed MBO. The primary outcome was clinical success (reduction in bilirubin of >50% at 30 days). Secondary outcomes were technical success, type of stent used, need for re-intervention, adverse events (AEs), time from stent placement to surgery or cancer centre assessment, and survival. Result(s) Between January 2020 and June 2022, 222 patients (102 female, 46%) with a mean age of 70±1 years (range 34-93 years) underwent 290 ERCPs. The cause of MBO was pancreatic cancer in 130 (59%), cholangiocarcinoma in 32 (14%), ampullary cancer in 9 (4%), and others in 51 (23%). Technical success for stent insertion on first ERCP was achieved in 180/222 patients (81%) with only brushings performed in 2. Of the 40 patients (18%) with unsuccessful ERCP, further success was achieved by repeat ERCP (8), percutaneous transhepatic drainage (PTC, 15), PTC with rendezvous ERCP (1), surgical decompression (3), and endoscopic ultrasound-guided biliary drainage (1). No biliary drainage was performed in 12 patients. Overall, ERCP with stent insertion was technically successful in 188/222 patients (85%). A total of 233 biliary stents were inserted (38 plastic, 195 metal). Clinical success was achieved in 20/38 patients (53%) with plastic stents and 151/181 patients (83%) with metal stents (Χ2 17.4 p<0.05). Adverse events were encountered in 33 patients (11%) with stent migration occurring in 8 (3%), cholangitis in 7 (2%), post-ERCP pancreatitis in 7 (2%), post-sphincterotomy bleeding in 4 (1%), and death in 2 (1%). Re-intervention was required in 36 patients (20%) after initial ERCP with successful stent placement. The re-intervention rate was significantly higher with plastic stents (14/27, 52%) than with metal stents (22/153, 14%) after initial ERCP (Χ2 20.1 p<0.001). The overall survival was a mean of 249±16 days (5-967) for patients with plastic stents and 248± 16 days (1-959) for those with metal stents. Survival was significantly worse in patients with unresectable disease vs resectable/borderline-resectable disease (Log rank 38.89, p<0.001), Figure 1. Image Conclusion(s) In MBO, metal stents appear to provide significantly better biliary drainage, with less need for re-intervention, but do not appear to be associated with any survival benefit over plastic stents. We hope that this quality assurance project will help in the development of a regional management pathway for optimizing the care of patients presenting with MBO. Please acknowledge all funding agencies by checking the applicable boxes below None Disclosure of Interest None Declared

Jaundice and a testicular lump: a rare cause of malignant biliary obstruction

Biliary obstruction from metastatic deposits in the pancreas is rare. We present a case of primary testicular lymphoma (PTL) with pancreatic metastasis. A 56-year-old man presented to the general surgical department with signs and symptoms of obstructive jaundice. A computed tomography scan revealed multiple pancreatic metastases and a right primary testicular malignancy. Histology and positron emission tomography scanning subsequently confirmed PTL with pancreatic metastases. Metastasis to the pancreas from primary testicular malignancy is extremely rare. There is variation in prognosis between primary and secondary pancreatic malignancies and therefore in atypical cases of malignant biliary obstruction consideration must be given to the rarer secondary malignancies.

Endoscopic radiofrequency ablation for malignant biliary obstruction

Cholangiocarcinoma and pancreatic cancer are the most common causes of malignant biliary obstruction. The majority of patients are diagnosed at a late stage when surgical resection is rarely possible. In these cases, palliative chemotherapy and radiotherapy provide only limited benefit and are associated with poor survival. Radiofrequency ablation (RFA) is a procedure for locoregional control of tumours, whereby a high-frequency alternating current turned into thermal energy causes coagulative necrosis of the tissue surrounding the catheter. The subsequent release of debris and tumour antigens by necrotic cells can stimulate local and systemic immunity. The development of endoluminal RFA catheters has led to the emergence of endoscopically delivered RFA, a treatment mainly used for malignant biliary strictures to prolong survival and/or stent patency. Other indications include recanalisation of occluded biliary stents and treatment of intraductal ampullary adenoma or benign biliary strictures. This article presents a comprehensive review of endobiliary RFA, mainly focusing on its use in patients with malignant biliary obstruction. The available data suggest that biliary RFA may be a promising modality, having positive impacts on survival and stent patency and boasting a reasonable safety profile. However, further studies with better characterised and stratified patient populations are needed before the method becomes accepted within routine clinical practice.

CONTRAST-ENHANCED COMPUTED TOMOGRAPHIC CHOLANGIOGRAPHY IN DIFFERENTIAL DIAGNOSIS OF THE MALIGNANT AND BENIGN CAUSES OF BILIARY OBSTRUCTION

Introduction. Determination of the cause of cholestasis and treatment of patients with obstructive jaundice syndrome remains challenging owing to the steady rise in diseases of the hepatopancreatoduodenal zone and the high frequency of diagnostic errors. In the differential diagnosis of the causes of obstructive jaundice, diagnostic imaging techniques are of the greatest importance. In the world literature, there are few reports on the assessment of the diagnostic potential of multispiral computed tomography under conditions of direct contrasting of the biliary tree using endoscopic retrograde cholangiopancreatography, percutaneous transhepatic cholangiography, or through pre-installed palliative drainage in the bile ducts. There is no generally accepted algorithm for determining the causes of biliary obstruction. It leads to ineffective use of various diagnostic imaging techniques, complicating the diagnostic process.The purpose of the study was to evaluate the diagnostic efficacy of contrast-enhanced ct cholangiography (ct-cg) in the differential diagnosis of causes of malignant and benign biliary obstruction in cases with obstructive jaundice syndrome.Material and methods. The study included 55 patients with obstructive jaundice, who were treated in a surgical hospital from july 2016 to july 2019.Results. It was found that contrast ct-cg in diagnosing the causes of biliary obstruction of both malignant and benign genesis is more informative than x-ray endoscopic retrograde cholangiopancreatography. The diagnostic efficacy of ct-cg in detecting causes of malignant biliary obstruction was: 93.3% sensitivity, 92.9% specificity, and 93.1% accuracy. The diagnostic efficacy of ct-cg in detecting causes of benign biliary obstruction was: 92.9%, 93.3% and 93.1%, respectively.Conclusion. Based on the high accuracy, contrast-enhanced ct-cg is a promising imaging technique in cases with bile duct obstruction.

BACTERIAL ISOLATES AND ANTIBIOTIC SENSITIVITY PATTERNS IN CHOLEDOCHAL BILE COLLECTED DURING ERCP: A REPORT FROM CENTRAL INDIA.

Temporal shifts have been known to occur in antibiotic sensitivity patterns of organisms causing cholangitis.The aim of this prospective study conducted on 100 patients of extra hepatic biliary obstruction (EHBO) was to identify the common microorganisms cultured from bile obtained during Endoscopic retrograde cholangiography and to study their local sensitivity pattern.Sixty six patients had growth in bile culture,the maximum growths amongst all micro-organisms were of Escherichia coli (40.9%) and Pseudomonas aeruginosa (40.9%). Growth rates were significantly higher in patients with non- malignant causes of biliary obstruction than those with malignant causes. Polymixins had the highest sensitivity to cultured bacteria followed by aminoglycosides and Imipenem.Study of culture & sensitivity pattern helps in deciding empirical antibiotic therapy in patients with cholangitis and it should be based on local sensitivity patterns

Su1327 ENDOSCOPIC ULTRASOUND GUIDED CHOLEDOCHODUODENOSTOMY IS A DURABLE, SAFE AND SUCCESSFUL PROCEDURE IN MALIGNANT BILIARY OBSTRUCTION

Endoscopic retrograde cholangiopancreatography (ERCP) with biliary stenting is the standard therapy for palliation of malignant biliary obstruction (MBO). In cases of failed ERCP, patients can undergo either percutaneous transhepatic cholangiography (PTC) drainage or endoscopic ultrasound-guided drainage, including choledochoduodenostomy (EUS-CD). The aim of this study is to compare PTC drainage to EUS-CD in patients with malignant biliary obstruction and failed ERCP. We performed a retrospective cohort study of patients with MBO and failed ERCP identified at Mayo Clinic Rochester from the 2014-2019. Patients with benign biliary obstruction or altered anatomy were excluded. Primary outcomes were technical and clinical success (bilirubin decrease of at least by 50% at 1 week). Secondary outcomes were adverse events (AEs), need for reintervention and survival. Cox regression analysis was used to compare time to reintervention and survival. A total of 36 patients (26 PTC, 13 CD) with malignant biliary obstruction who failed ERCP were included. There were no significant differences between the groups (Table 1). The causes of MBO were pancreatic adenocarcinoma 22 (61.1%), gastroduodenal adenocarcinoma 6 (16.7%), metastatic disease 5 (13.9%), cholangiocarcinoma 2 (5.5%) and myxoid sarcoma 1 (2.8%). Duodenal stricture preventing access to the major papilla was the main cause for failed ERCP in 17 patients (47.2%). Lumen apposing metal stents were used for CD in 9 patients (69.2%). A 10 Fr catheter was used for initial PTC for all patients in the PTS group. Technical and clinical success was 95.6% and 77.3% in the PTC group and 100% and 92.3% in the CD group, P=0.45 and P=0.25. There was one stent maldeplolyment in the CD group which was managed immediately with re-stenting and no immediate AE in the PTC group. Long term AEs were fewer in the CD group (0%) compared to the PTC group (7; 30.4%, P=0.01). The most common AE in the PTC group was clinically significant catheter occlusion in 5 patients (21.7%). 14 patients (60.9%) with PTC required reintervention compared to 0 (0%) after CD, P<0.001. Half of the reinterventions after PTC (7) were elective tube exchanges. There was no significant difference in survival between the two groups HR: 0.75 (95% CI: 0.3 -1.8, P=0.5). EUS-CD is a technically and clinically highly successful procedure without an increased risk for AEs in malignant biliary obstruction after failed ERCP. EUS-CD reduces reinterventions, which enhances end of life quality in patients with advanced malignancy.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Long-term outcomes of a long, partially covered metal stent for EUS-guided hepaticogastrostomy in patients with malignant biliary obstruction (with video)

We previously reported safety and effectiveness of EUS-guided hepaticogastrostomy (EUS-HGS) using a long, partially covered metal stent (LP-CMS) for malignant biliary obstruction (MBO). In this study, we aimed to evaluate long-term outcomes of EUS-HGS in an expanded cohort. One hundred ten patients undergoing EUS-HGS using an LP-CMS in 2 centers were retrospectively studied. Technical and functional success, adverse events, recurrent biliary obstruction (RBO), and reinterventions were evaluated. The cause of MBO was pancreatic cancer in 50%, and the location of MBO was distal in 68%. The stent length was 8 cm in 2%, 10 cm in 84%, and 12 cm in 15%, with a median intragastric stent length of 54mm. Technical and functional success rates were 100% and 94%, respectively. The adverse event rate was 25% (mild 15%, moderate 7%, severe 3%), but about one-half of adverse events were mild transient fever and abdominal pain. RBO developed in 33%, with a median cumulative time to RBO of 6.3 months. The major cause of RBO was hyperplasia at an uncovered portion. The presence of prior biliary drainage and short intragastric stent length were significantly associated with RBO. Reintervention for RBO was successfully achieved through the EUS-HGS route in 92%. The remaining reintervention procedures were 1 EUS-HGS and 2 percutaneous transhepatic biliary drainage all in cases with hilar MBO. EUS-HGS using an LP-CMS for unresectable MBO was safe and effective. RBO was not uncommon, butreintervention through the EUS-HGS route was technically possible in most cases.

Left versus right-sided percutaneous transhepatic biliary drainage in relief of malignant obstruction

Background: Biliary tree obstruction and consequent jaundice occur in 70%–90% of these patients and have important consequences mainly for the patient's quality of life, morbidity, and overall mortality. Percutaneous transhepatic biliary drainage (PTBD) is an excellent palliative procedure to drain the bile ducts in malignant obstruction. We compared left- and right-sided approach in relief of malignant obstruction. The most common causes of malignant biliary obstruction (MBO) include pancreatic adenocarcinoma, hilar cholangiocarcinoma, ampullary/duodenal adenocarcinoma, gallbladder adenocarcinoma, lymphoma, and compressive metastatic peri-portal lymph node Materials and Methods: This study was a prospective, hospital-based study performed for 2 years from 2016 to 2018. PTBD was performed either through right in 16 patients or left approach in 15 patients. Two approaches were compared in terms of clinical and technological success, changes in laboratory data, internalization and survival. Results: (1) Rate of technological success was 100%. (2) There was a significant reduction in bilirubin, alanine transaminase (ALT), and alkaline phosphatase (ALP) levels after the procedure in both the approaches, but the decrease was more in the right-sided approach. Only the decrease in bilirubin levels was statistically significant. The decrease in albumin was attributed to the progression of the disease. (3) Clinical success was seen in 93.33% and 93.75% in left- and right-sided approach. (4) Internalization was done in 86.67% patients in the left-lobe approach, while as in right-lobe approach, it was done in 93.75% patients. Conclusion: PTBD causes a significant reduction in the bilirubin level, irrespective of the amount of liver drained or the type of drainage (external/internal). In our study, the reduction in bilirubin, ALT and ALP was more in the right-lobe approach. However, only reductions in levels of bilirubin were statistically significant.

Management of Biliary Strictures: State-of-the-Art Review.

Biliary strictures can be broadly classified as benign or malignant. Benign biliary strictures are most commonly iatrogenic in nature and are a consequence of hepatobiliary surgery. Cholangiocarcinoma and adenocarcinoma of the pancreas are the most common causes of malignant biliary obstruction. This article reviews state-of-the-art minimally invasive techniques used to manage these strictures. In addition, the roles of (a) recently introduced biodegradable biliary stents in the management of benign biliary strictures and (b) intraprocedural imaging and navigation tools, such as cone-beam CT, in percutaneous reconstruction of the biliary-enteric anastomosis are discussed.

Prospective multicenter study of primary EUS-guided choledochoduodenostomy using a covered metal stent

Background and Objectives:EUS-guided biliary drainage (EUS-BD) is increasingly reported as a salvage technique after failed endoscopic retrograde cholangiopancreatography, but it is still controversial whether EUS-BD can replace transpapillary biliary stenting. Therefore, we conducted this multicenter, prospective study of EUS-guided choledochoduodenostomy (EUS-CDS) using a covered metallic stent (CMS) as primary biliary drainage for unresectable distal malignant biliary obstruction (MBO).Methods:Patients with unresectable distal MBO without any prior drainage are enrolled. Primary endpoint is a technical success and secondary endpoints are adverse events, functional success, and recurrent biliary obstruction (RBO) of EUS-CDS. Clinical outcomes were compared between EUS-CDS and transpapillary stenting as a control.Results:A total of 34 patients were enrolled in 10 Japanese institutions. The cause of MBO was pancreatic cancer in 28 patients. Median tumor size and common bile duct diameter were 31 and 13 mm, respectively. Technical success rate was 97% with a median procedure time of 25 min and functional success rate was 100%. The rate of RBO was 29% and the causes of RBO were nontumor related: Migration in 18%, sludge/food impaction in 9%, and stent impaction to the duodenal wall in 3%. Other adverse events were abdominal pain in 6% and cholecystitis in 9%. A median cumulative time to RBO was 11.3 months. The rate of RBO and cumulative time to RBO of EUS-CDS were comparable to those of transpapillary stenting (36% and 9.1 months, respectively).Conclusion:EUS-CDS using a CMS as primary biliary drainage was technically feasible and its safety appeared comparable to transpapillary stenting.

Utilizing of MRCP/MRI in differentiation between benign and malignant biliary obstruction

Obstruction is one of the most common problems in biliary tree pathology, combined magnetic resonance imaging (MRI) and Magnetic Resonance Cholangiopancreatography (MRCP) regarded as accurate imaging modalities in diagnosis the cause of obstruction and treatment planning due to information obtain from MRCP about biliary and pancreatic ducts, information obtains from MRI cross sections about surrounding parenchyma. This study was aimed to investigate the efficacy of combined MRCP and MRI in differentiation between benign and malignant causes of biliary dilatation and their sensitivity in detection specific cause of biliary dilatation. This study involved 72 patients and conducted in Al-Diwaniyah Teaching Hospital, Iraq during a period from February 2013 to June 2017, the diagnosis of biliary dilatation was done by abdominal ultrasound to all patients followed by MRCP/MRI, the results of MRCP/MRI was compared with final diagnoses done by endoscopic retrograde cholangiopancreatography (ERCP), surgical, histopathological and laboratory results. The results revealed that a strong correlation between MRCP/MRI and other gold standard tools in differentiation between benign and malignant causes of obstruction. Sensitivity, specificity, and accuracy of MRCP in differentiation between malignant and benign causes of biliary dilatation were 98.4%, 100% &amp; 99.7% respectively. There was a strong correlation (0.990) between MRCP/MRI &amp; final diagnosis to determine the specific cause of obstruction, correct diagnosis the cause of obstruction in 68 patients out of 72 with a sensitivity of 94%. This study concluded that combined MRCP/MRI plays an important role in differentiation benign &amp; malignant causes of biliary obstruction and in differentiation the specific cause of obstruction.&#x0D; Keywords: MRI; MRCP; Biliary obstruction; ERCP

Role of Magnetic Resonance Cholangio-Pancreaticography in Differentiating between Benign and Malignant Causes of Biliary Obstruction

Background: the initial evaluation of obstructive jaundice involves distinguishing between intra and extra hepatic biliary obstruction. The goal of any radiologic procedure is to confirm the presence of biliary obstructive by detecting biliary dilatation, its exact location, extent and probable cause. Aim of the Study: to evaluate the role of Magnetic Resonance Cholangio-Pancreatography in differentiating benign from malignant causes of biliary obstruction using surgical, ERCP or histopathological findings as a gold standard.Patients and Methods: a prospective study done on 20 patients with clinical and laboratory finding suggestive of biliary obstruction. All patients underwent non enhanced MRCP on 1.5 Tesla machine (Philips). The final diagnosis of MRCP was correlated with results of ERCP in addition to biopsy and histological diagnosis to those patients had neoplasms. Results: Out of 20 cases, there were 11 benign and 9 malignant cases. Mean age of patients with malignant obstruction was more than benign with slight female preponderance. The diagnostic accuracy of MRCP in differentiating benign from malignant biliary obstructive diseases in correlation with surgical, ERCP and histopathological outcome was85.7%, 96.3%, and 93.3% respectively. It was found that irregular, asymmetric and long segment narrowing was more common in malignant stricture. Conclusion: MRCP is a rapid and non-invasive, procedure in assessing cases with suspicions biliary obstructions. It offered a diagnostic accuracy nearly equivocal to ERCP. MRCP can also replace the diagnostic part of ERCP procedure, so that time is spent only on its th erapeutic part, and hence decreasing complications of a lengthy ERCP. Recommendations: benign or malignant nature of biliary obstruction can be assured by MRCP by observation of stricture margin, dilatation, and length and accordingly proceed to next step in management. MRCP is an efficient diagnostic procedure for detection of presence, level, cause of obstruction and routinely advocated before any intervention is planned.

Risk-stratified versus Non-Risk-stratified Diagnostic Testing for Management of Suspected Acute Biliary Obstruction: Comparative Effectiveness, Costs, and the Role of MR Cholangiopancreatography.

Purpose To analyze the cost-effectiveness of the American Society for Gastrointestinal Endoscopy (ASGE) risk stratification guidelines versus magnetic resonance (MR) cholangiopancreatography-based treatment of patients with possible choledocholithiasis. Materials and Methods A decision-analytic model was constructed to compare cost and effectiveness of three diagnostic strategies for gallstone disease with possible choledocholithiasis: noncontrast MR cholangiopancreatography, contrast material-enhanced MR imaging/MR cholangiopancreatography, and ASGE risk stratification guidelines for diagnostic evaluation recommending endoscopy (high risk), MR cholangiopancreatography (intermediate risk), or no test (low risk). Analysis was performed from a U.S. health system perspective over 1-year and lifetime horizons. The model accounted for benign and malignant causes of biliary obstruction and procedural complications. Cost information was based on Medicare reimbursements. Sensitivity analysis assessed the impact of parameter variability on model results. Results Noncontrast MR cholangiopancreatography was most cost-effective in 45-55-year-old patients (less than $100 000 per quality-adjusted life-year [QALY] gained), while contrast-enhanced MR imaging was favored in younger adults. Risk-stratified testing was less costly than MR cholangiopancreatography, with long-term savings of $1870 and $2068 versus noncontrast and contrast-enhanced MR cholangiopancreatography, respectively, but was also less effective (-0.1814, -0.1831 QALY, respectively). The lifetime incremental cost per QALY for noncontrast MR cholangiopancreatography was $10 311. Contrast-enhanced MR imaging was favored with pretest probabilities of biliary stricture or malignancy 0%-73% for patients aged 20-44 years. For patients older than 55 years, ASGE guidelines maximized QALYs at the lowest cost. Conclusion Although adults older than 55 years of age are optimally evaluated by using ASGE guidelines, younger patients suspected of having acute biliary obstruction likely benefit from MR cholangiopancreatography rather than risk-stratified diagnostic imaging because of improved detection of choledocholithiasis and alternative causes of biliary obstruction. © RSNA, 2017 Online supplemental material is available for this article.

Long-term outcomes and reintervention of endoscopic ultrasound-guided biliary drainage for malignant biliary obstruction: A multicenter retrospective analysis of 96 cases

Background and Objectives:Although EUS-guided biliary drainage (EUS-BD) for malignant biliary obstruction (MBO) is increasingly reported, its long term outcomes are not fully discussed.Methods:Consecutive patients undergoing EUS-BD for unresectable MBO were retrospectively studied. Data on recurrent biliary obstruction (RBO) including re-intervention and other stent-related complications were extracted.Results:Between Aug 2011 and Dec 2016, EUS-BD was performed in 96 patients (82 EUS-HGS and 14 EUS-CDS, 95 covered metal stent [CMS] and 1 plastic stent) at 4 tertiary referral centers. Biliary drainage prior to EUS-BD had been performed in 54%. The major causes of MBO were pancreatic cancer (52%) and biliary tract cancer (28%). Duodenal invasion (64%) and surgically altered anatomy (25%) were two major reasons for EUS-BD. Technical success rate was 98% with two technical failures (1 stent misplacement and 1 failed insertion of CMS delivery). The incidence of RBO was 36% and a median cumulative time to RBO was 6.8 months. The causes of RBO were non-tumor related (hyperplasia 17%, migration 9%, sludge 5%, reflux 2% and kink 2%), other than de novo stricture (2%). Re-intervention was successfully performed via EUS-BD route in 89% (22 stent-in-stent, 5 balloon sweep, 3 stent exchange and 1 additional antegrade stenting). Other re-interventions were 2 conversion to transpapillary stenting, 1 conversion from CDS to HGS and 1 PTBD. The incidence of other complications was 29%.Conclusions:The incidence of RBO necessitating re-interventions was not rare in EUS-BD for MBO but re-intervention via EUS-BD route was technically feasible in most cases.

Role of MRCP in Differentiation of Benign and Malignant Causes of Biliary Obstruction.

Differentiation of the benign and malignant etiology of biliary obstruction is difficult. We studied the diagnostic accuracy of MRCP (Magnetic Resonance Cholangio-pancreatography) in differentiating between benign and malignant causes of biliary obstruction. To evaluate the role of Magnetic Resonance Cholangio-Pancreatography in differentiating benign from malignant causes of biliary obstruction using surgical, ERCP or histopathological findings as gold standard. Seventy five patients with clinical and laboratory finding suggestive of biliary obstruction underwent MRI/MRCP. The final diagnosis was based on either surgical findings, histopathology of resected specimen or ERCP findings. Diagnostic effectivity of MRCP was calculated which included sensitivity, specificity and accuracy. Statistical analysis was done by using chi-square test and p value was calculated. Out of 75 cases, there were 54 benign and 21 malignant cases. Mean age of patients with malignant obstruction was more than benign with slight male preponderance. The diagnostic accuracy of MRCP in differentiating benign from malignant biliary obstructive diseases in correlation with surgical, ERCP and histopathological outcome was 93.3%, sensitivity 85.7%, specificity 96.3%. It was found that irregular, asymmetric and long segment narrowing was more common in malignant stricture. MRCP is the investigation of choice for suspected choledocholithiasis, choledochal cyst and primary sclerosing cholangitis. A benign stricture can be differentiated from a malignant one if it shows regular, symmetric and short segment narrowing. Irregular, asymmetric and long segment narrowing was more commonly found in malignant stricture.

Self-Expandable Metal Stents in Malignant Biliary Obstruction

: Malignant biliary obstruction can be due to direct tumor infiltration, extrinsic compression, adjacent inflammation, desmoplastic reaction from tumors or, more commonly, a combination of the above factors. Pancreatic cancer is the most common cause of malignant biliary obstruction, and jaundice occurs in 7090% of the patients during the course of the disease. Compared with the uncovered metal stents, covered metal stents have longer patency and a lower rate of tumor ingrowth, but have a higher rate of stent migration. To combat the occlusion and provide an antitumor effect, drug-eluting stents were developed. A duodenal stricture complicates biliary stent placement in 10-20% of patients with distal biliary obstruction due to pancreatic cancer. When both strictures are considered, a biliary stent can be placed either preceding or following duodenal stent placement. Complications of self-expandable metal stents include stent occlusion, stent migration, cholecystitis and pancreatitis.

Periampullary Lymphoma Masquerading as Adenocarcinoma

Adenocarcinoma is the most common tumor of the peri-ampullary region, while peri-ampullary lymphoma (PAL) is a very rare malignancy. In a retrospective analysis of 1123 biliary obstruction patients, Non-Hodgkins Lymphoma (NHL) was found in only 4 (0.35 %) and obstructive jaundice was found in only one and in other case series it was the cause of malignant biliary obstruction in 1–2 % [1]. Various hematological malignancies can involve the peri-ampullary region, most commonly as follicular lymphoma. Diffuse large B-cell lymphoma (DLBCL) in this region is very rare and may mimic carcinoma [2]. The PAL can have variable clinical presentations; diagnosis is by endoscopic or laparoscopic biopsy with immunohistochemistry (IHC). In general jaundice in DLBCL is usually caused by enlarged lymph nodes compressing the hepatic hilar or peri-pancreatic region and DLBCL presenting as peri-ampullary mass with obstructive jaundice is rarely seen [3]. We report a case of DLBCL involving the peri-ampullary region presenting as obstructive jaundice and masquerading as adenocarcinoma.

The Role of Endoscopic Ultrasound in Biliary Obstruction

The role of endoscopic ultrasound (EUS) in the diagnosis of biliary obstruction is well established, and emerging evidence suggests it may also play a therapeutic role. Differentiating between benign and malignant causes of biliary obstruction can be challenging, but EUS is a crucial tool in the armamentarium of the physician. Evolving technologies such as elastography and contrast enhancement may further supplement the diagnostic abilities of EUS. Therapeutic applications of EUS are evolving rapidly, and EUS-guided cholangiography may aid biliary decompression when endoscopic retrograde cholangiopancreatography (ERCP) has failed or is not possible.

Can red cell distribution width help to discriminate benign from malignant biliary obstruction? A retrospective single center analysis.

Differentiation of benign obstructive jaundice from malignant obstructive jaundice still remains difficult, despite improvements in diagnostic modalities. The aim of this study is to evaluate the usefulness of red cell distribution width (RDW) in differentiating benign and malignant causes of obstructive jaundice. One hundred and ninety four consecutive patients (101 malignant, 93 benign) with a history of obstructive jaundice were reviewed in the period between January 2008 and August 2009. Definition of biliary strictures was suggested by cholangiographic features and supported by brush cytology, fine needle aspiration (FNA) and the presence of mass or metastases by imaging and/or clinical followup. Patients were divided into two groups, benign and malignant, based on the discharge diagnosis. The receiver operating characteristic analysis showed that a RDW of 14.8% was the best cut-off value for predicting a malignant biliary stricture with a sensitivity of 72% and a specificity of 69% (AUC=0.755, 95% CI=0.649-0.810). RDW was increased (>14.8%) in 31.6% of benign cases and 68.4% of malignancies. Depressed RDW levels (<14.8%) were found in 72.9% of benign cases and 27.1% of malignancies, which was statistically significant (p<0.001). Our results show that RDW is useful in the differentiation of benign from malignant causes of biliary obstruction when using an optimized cut-off value. In patients in whom biliary obstruction is suspected, an elevated RDW value may be a reliable additional predictor for differentiating the underlying etiology of biliary obstruction.

Self-expandable metal stents in malignant biliary obstruction

Malignant biliary obstruction can be due to direct tumor infiltration, extrinsic compression, adjacent inflammation, desmoplastic reaction from tumors or, more commonly, a combination of the above factors. Pancreatic cancer is the most common cause of malignant biliary obstruction, and jaundice occurs in 70–90% of the patients during the course of the disease. Compared with the uncovered metal stents, covered metal stents have longer patency and a lower rate of tumor ingrowth, but have a higher rate of stent migration. To combat the occlusion and provide an antitumor effect, drug-eluting stents were developed. A duodenal stricture complicates biliary stent placement in 10–20% of patients with distal biliary obstruction due to pancreatic cancer. When both strictures are considered, a biliary stent can be placed either preceding or following duodenal stent placement. Complications of self-expandable metal stents include stent occlusion, stent migration, cholecystitis and pancreatitis.