Diagnosis Of Biliary Strictures Research Articles

Impact of different ischemia times on biliary stricture after living donor liver transplantation with biliary atresia.

Biliary atresia (BA) is the most common indication for pediatric liver transplantation, and biliary stricture (BS) remains an Achilles' heel for pediatric living donor liver transplantation (LDLT). We investigated the impact of different ischemia times on BS after LDLT in patients with BA. We retrospectively analyzed patients (<18y) with BA who underwent LDLT between January 2016 and December 2020. Cases with hepatic artery thrombosis, bile leakage, early BS (<2wk), and early death (<3mo) were excluded. In all, 572 cases were included. A total of 26 cases (4.55%, 26/572) developed BS: 25 patients with anastomotic stricture and 1 patient with anastomotic stricture combined with left hepatic duct stricture. In addition, the time to diagnosis of BS ranged from 1.8 to 53.0 months (mean, 13.0mo and median, 8.2mo) after transplantation. A multivariate logistic regression analysis showed that arterial ischemia time (AIT), per 10 minutes (OR=1.222, 95% CI: 1.007-1.438, p =0.04) was the only independent risk factor for the development of BS after LDLT in patients with BA. What is more, the 5-year cumulative risk of BS between the AIT ≥40 minutes and AIT <40 minutes groups was 2.79% versus 10.57%. AIT was the only independent risk factor for the development of BS after LDLT with BA, and AIT ≥40 minutes would increase the 5-year cumulative risk of BS in our study. A shorter AIT, especially AIT <40 minutes, should be kept to decrease BS.

Long-term Clinical Outcomes and Predictive Factors for Living-donor Liver Transplant Recipients With Biliary Strictures.

Biliary strictures frequently occur in living-donor liver transplant (LDLT) recipients. However, long-term clinical outcomes and their associated factors are unclear. We analyzed an historical cohort of 228 recipients who underwent LDLT with post-liver transplantation biliary strictures. Endoscopic retrograde cholangiography or percutaneous transhepatic biliary drainage were performed to treat biliary strictures. Patients that experienced persistent jaundice over 3 mo after the initial treatment were defined as a remission-failure group. Median observation period was 8.5 y after the diagnosis of biliary stricture. The 15-y graft survival (GS) rate was 70.6%, and 15-y rate of developing portal hypertension (PH) was 26.1%. Remission failure occurred in 25.0% of study participants. In the multivariate analysis, biopsy-proven acute rejection, and portal vein/hepatic artery abnormalities were risk factors for remission failure. Development of PH, retransplantation, and death were significantly more frequent in the remission-failure group. Remission failure and PH were associated with poor GS. In multivariate analyses, hepatic artery abnormality and biloma were common significant factors that were associated with a poor GS and development of PH. The insufficient blood supply reflected by hepatic artery abnormality and biloma might be the most important factor that can predict poor long-term survival in LDLT patients with biliary strictures. Future large-scale prospective studies are needed to validate our observations.

The Role of Cholangioscopy and EUS in the Evaluation of Indeterminate Biliary Strictures

Bile duct stenosis continues to present a diagnostic dilemma for clinicians. It is important to establish the benign or malignant nature of the stricture early in order to avoid any unnecessary delay in medical treatment or surgery. Tissue acquisition for histological diagnosis is particularly crucial when the initial diagnostic work up is inconclusive. The diagnostic yield from the conventional endoscopic retrograde cholangiopancreatography (ERCP) with brushing and biopsy is suboptimal. Patients with indeterminate biliary strictures (IDBSs) often require a multi-disciplinary diagnostic approach and additional endoscopic evaluation, including cholangioscopy and endoscopic ultrasound, before a final diagnosis can be reached. In this article, we discuss the recent endoscopic advancements in the diagnosis of biliary stricture with a focus on the roles of cholangioscopy and endoscopic ultrasound (EUS).

Diagnostic value of peroral cholangioscopy in addition to computed tomography for indeterminate biliary strictures.

Peroral cholangioscopy (POCS) has been used to overcome the difficulty in diagnosing indeterminate biliary stricture or tumor spread. However, the value of adding POCS to computed tomography (CT) remains unclear. Our aim was to evaluate the diagnostic value of adding POCS to CT for indeterminate biliary stricture and tumor spread by interpretation of images focusing on the high diagnostic accuracy of visual findings in POCS. We retrospectively identified 52 patients with biliary stricture who underwent endoscopic retrograde cholangiography (ERC) at our institution between January 2013 and December 2018. Two teams, each composed of an expert endoscopist and surgeon, performed the interpretation independently, referring to the CT findings of the radiologist. The CT + ERC + POCS images (POCS group) were evaluated 4weeks after the evaluation of CT + ERC images (CT group). A 5-point scale (1: definitely benign to 5: definitely malignant) was used to determine the confident diagnosis rate, which was defined as an evaluation value of 1 or 5. Tumor spread was also evaluated. In the evaluation of 45 malignant diagnoses, the score was significantly closer to 5 in the POCS group than in the CT group in both teams (P < 0.001). The confident diagnosis rate was significantly higher for the POCS group (92% and 73%) than for the CT group (25% and 12%) in teams 1 and 2, respectively (P < 0.001). We found no significant difference in diagnostic accuracy for tumor spread between the groups. Visual POCS findings confirmed the diagnosis of biliary strictures. POCS was useful in cases of indefinite diagnosis of biliary strictures by CT.

Biliary Strictures: A Surgeon's Perspective for Interventional Radiologists.

Biliary strictures can be a challenging clinical problem to manage and often have unclear etiologies, including benign and malignant causes. Left untreated, these problems can lead to significant morbidity and mortality linked to their underlying diagnosis. The approach to adult patients with biliary strictures requires a multidisciplinary team involving surgeons, interventional endoscopists, and interventional radiologists for diagnosis, symptom relief, palliation, as well as potential curative management. From a surgeon's perspective, there are many ways to classify and approach these strictures. It is of paramount importance to start with an excellent understanding of the patient's prior surgical history. In approaching a patient with a new diagnosis of biliary stricture, it is also critical to understand its etiology relatively quickly, as 70% are malignant in the adult population. Concurrently, one must clearly define the location and extent of the stricture: intrahepatic, hilar, or distal extrahepatic bile duct, as well as whether it is a singular lesion or multifocal phenotypes. This information provides a path forward in clinical decision-making regarding durability and efficacy of therapy, which is typically aimed at decompression and/or surgical resection to prevent cholangitis, sepsis, and progressive hepatic insufficiency.

Diagnosing Biliary Strictures: Distinguishing IgG4-Related Sclerosing Cholangitis From Cholangiocarcinoma and Primary Sclerosing Cholangitis.

Biliary strictures caused by inflammation or fibrosis lead to jaundice and cholangitis which often make it difficult to distinguish malignant strictures. In cases when malignancy cannot be excluded, surgery is often performed. The concept of immunoglobulin G4 (IgG4)–related sclerosing cholangitis (SC) as a benign biliary stricture was recently proposed. The high prevalence of the disease in Asian countries has resulted in multiple diagnostic and treatment guidelines; however, there is need to formulate a standardized diagnostic strategy among various countries considering the utility, invasiveness, and cost-effectiveness. We evaluated accuracies of various diagnostic modalities for biliary strictures comparing pathology in the Delphi meetings which were held in Rochester, MN. The diagnostic utility for each modality was graded according to the experts, including gastroenterologists, endoscopists, radiologists, and pathologists from the United States and Japan. Diagnostic utility of 10 modalities, including serum IgG4 level, noninvasive imaging, endoscopic ultrasound, endoscopic retrograde cholangiopancreatography–related diagnostic procedures were advocated and the reasons were specified. Serum IgG4 level, noninvasive imaging, diagnostic endoscopic ultrasound and intraductal ultrasonography under endoscopic retrograde cholangiopancreatography were recognized as useful modalities for the diagnosis. The information in this article will aid in the diagnosis of biliary strictures particularly for distinguishing IgG4–SC from cholangiocarcinoma and/or primary SC.

Endoscopic Evaluation of Biliary Strictures: Current and Emerging Techniques.

The diagnosis of biliary strictures in clinical practice can be challenging. Discriminating between benign and malignant biliary strictures is important to prevent the morbidity and mortality associated with incorrect diagnoses. Missing a malignant biliary stricture may delay surgery, resulting in poor prognostic outcomes. Conversely, it has been demonstrated that approximately 20% of patients who undergo surgery for suspected biliary malignancies have a benign etiology on histopathology. Traditional tissue sampling using endoscopic retrograde cholangiography does not always produce a definitive diagnosis, with a considerable proportion of cases remaining as indeterminate biliary strictures. Recent advances in endoscopic techniques have the potential to improve the diagnostic and prognostic accuracy of biliary strictures.

Primary Cholangioscopy Versus ERCP in the Diagnosis of Biliary Strictures

Primary Cholangioscopy Versus ERCP in the Diagnosis of Biliary Strictures

Risk Factors and Predictors of Poor Outcome Following Hepaticojejunostomy for Postcholecystecomy Bile Duct Injury

Bilio-enteric anastomosis is the main line of treatment of bile duct injury (BDI). This study aims at exploring factors related to poor outcome after surgical reconstruction especially operative factors. Special emphasis on Hepp-Couinaud technique, theoretically, ensuring larger stoma and better blood supply. Between January 1992 and July 2015, 321 cases of postcholecystectomy BDI underwent hepaticojejunostomy. Retrospective analysis of demographics, perioperative data and management, and outcome according to Terblanche et al. Development of anastomotic strictures (AS) was evaluated. The mean follow-up time was 84.7 ± 61.9 months. Women represented 76% of all cases with a mean age of 40.1 ± 12.8. ERCP was performed in 105 (32.7%) patients. E2 and E3 strictures accounted for 76% of cases. One hundred thirty-seven (42.7%) patients underwent an end-to-side HJ. Abdominal collection or biloma was the commonest complication. Anastomotic stricture occurred in 16 (5.2%) patients after a mean time of 45 ± 31.3 months. Excellent or good outcome was detected in 281 (91.8%) patients, while fair or poor outcome was proved in 25 (8.2%) patients. On multivariate analysis, the only significant factors that predict a poor outcome were post-ERCP pancreatitis (p = 0.008), the design of HJ as end to side (p = 0.033), and postoperative biloma or abdominal collection (p = 0.021). On multivariate analysis, the only factor that was found to significantly affect the development of AS was postoperative development of collection or biloma (p = 0.032). HJ has very good results in specialized centers. Careful operative technique with sound wide stoma improves the outcome. ERCP should be used selectively and with caution for diagnosis of biliary strictures.

Spyglass visual impression and Spybite targeted biopsies for diagnosis of biliary strictures of unknown reasons: a meta-analysis

Objective To study the diagnostic value of Spyglass visual impression and Spybite targeted biopsies for biliary strictures of unknown reasons. Methods Several Chinese and English databases were electronically searched for studies on biliary strictures diagnosed with Spyglass visual impression and Spybite targeted biopsies compared with golden standard (pathological biopsy, autopsy and long-term clinical follow-up). The methodological quality of the included studies was assessed according to QUADAS-2 items. The software Meta-DiSc (version 1.4) was used to conduct pooling on sensitivity, specificity, positive likelihood radio, negative likelihood radio and diagnostic odds ratio (DOR). Heterogeneity test was performed and the summary receiver operating characteristic curve (SROC) was drawn for area under the curve (AUC). Results A total of 12 studies met the inclusion criteria, involving 532 patients who received Spyglass visual impression and 525 who received Spybite targeted biopsies. The combined specificity, sensitivity, positive likelihood ratio, negative likelihood ratio and DOR were 0.90 (95%CI: 0.85-0.94), 0.89 (95%CI: 0.85-0.93), 7.12 (95%CI: 4.36-11.64), 0.12 (95%CI: 0.07-0.22)and 82.40 (95%CI: 33.73-201.28)for Spyglass visual impression, and 0.98 (95%CI: 0.96-1.00), 0.66 (95%CI: 0.60-0.71), 13.29 (95%CI: 6.92-25.53), 0.37 (95%CI: 0.28-0.47)and 51.05 (95%CI: 23.58-110.53) for Spybite targeted biopsies, respectively. The AUC on the SROC of Spyglass visual impression and Spybite targeted biopsies were 0.957 4 and 0.939 8, respectively. Conclusion Spyglass visual impression is useful for detecting malignant lesion, whereas Spybite targeted biopsies is better at confirming malignant diagnosis, which indicates combination of the two methods have good diagnostic value for indeterminate biliary strictures, but their negative results are not perfect in excluding biliary cancer. Key words: Meta-analysis; Spyglass direct visualization system; Spybite tageted biopsy; Indeterminate biliary stricture

Comparison of biliary brush biopsy and fine needle biopsy in the diagnosis of biliary strictures

Purpose: The purpose of this study is to evaluate the accuracy of percutaneous fine needle biopsy (FNB) and brush biopsy (BB) at a cancer center.Material and methods: Retrospective analysis of all bile duct biopsies performed in Interventional Radiology between January 2000 and January 2015 was performed. FNB was performed under real-time cholangiographic guidance using a notched needle directed at the bile duct stricture. BB was performed by advancing a brush across the stricture and moving it back and forth to scrape the stricture. Biopsy results were categorized as true positive (TP), true negative (TN), false positive (FP) and false negative (FN) based on pathology reports and confirmed by surgical specimens or clinical follow-up of at least six months. Fisher’s exact test was used to compare the rate of TP in FNB and BB.Results: One-hundred and nineteen patients underwent FNB or BB. Fifteen were censored because of lack of follow-up. The remaining 104 patients underwent a total of 117 bile duct biopsies during the study period: 34 FNB and 83 BB. There were no complications in either group. In the FNB group 22/34 (64%) biopsies were TP, 4/34(12%) were TN and there were 8(24%) FN biopsies. In the BB group, 20/83 (24%) were TP, 38/83 (46%) TN and 25/83 (30%) FN biopsies. There were no FP biopsies in either group. The sensitivity of detecting malignancy by FNB was significantly higher than that by BB (73% vs 44%, p < .0005). There were no complications associated with FNB or BB.Conclusions: FNB of bile duct strictures is safe and has a higher sensitivity for detecting malignancy than BB.

Tu1437 10 Years of Experience Using Fish for the Diagnosis of Biliary Strictures

Tu1437 10 Years of Experience Using Fish for the Diagnosis of Biliary Strictures

Tu1465 The Effectiveness of Endoscopic Transpapillary Biopsy Alone for the Diagnosis of Biliary Strictures Using Novel Biopsy Forceps: Single-Center Experience With Large Cases

Tu1465 The Effectiveness of Endoscopic Transpapillary Biopsy Alone for the Diagnosis of Biliary Strictures Using Novel Biopsy Forceps: Single-Center Experience With Large Cases

The Accuracy of Transpapillary Forceps Biopsy and Brush Cytology for the Diagnosis of Biliary Strictures with Pancreatic Cancer and the Factors Contributing to Success of Pathological Diagnosis

The Accuracy of Transpapillary Forceps Biopsy and Brush Cytology for the Diagnosis of Biliary Strictures with Pancreatic Cancer and the Factors Contributing to Success of Pathological Diagnosis

A Case Report of IgG4-Related Autoimmune Cholangitis

Introduction: Autoimmune cholangitis is a biliary manifestation of IgG4 related disease (IgG4-RD) which can affect many organs and only rarely occurs in the absence of autoimmune pancreatitis. We present a case of IgG4 related cholangitis and discuss differential diagnosis and the role of clinical, laboratory and radiologic findings in establishing the diagnosis. Methods: N/A. Results: A 66 year old man was sent to the ED from his gastroenterologist's office for 3 weeks of jaundice, lower abdominal cramping, pale yellow stools 3-4 times daily, and dark orange urine. An outpatient abdominal ultrasound showed biliary obstruction and diffuse thickening of the common duct. In the ED, the patient appeared jaundiced but hemodynamically stable. Laboratory studies showed total bilirubin 11, direct bilirubin 8.9, AST 60, ALT 45, ALKP 265, amylase 65, and lipase 278. MRCP showed proximal and distal common bile duct strictures with intrahepatic and common duct dilation, circumferential biliary hyperenhancement, and bilateral striated heterogeneous nephrograms. The combination of these findings suggested the possibility of autoimmune cholangitis. ERCP was not initially performed due the location of the more proximal stricture and the possible risk of bacterial seeding of an obstructed biliary system. IgG4 levels were drawn and the patient was discharged on prednisone 40mg daily. Total IgG level and IgG4 returned elevated at 2641 and 459, respectively. Antinuclear antibody and anti-smooth muscle antibody were negative. After 2 weeks of steroid therapy, total bilirubin decreased to 2.4. Conclusion: IgG4 associated cholangitis was first described in the literature in 1995 and since then, there have been only a few case reports. IAC can further be classified into type 1 or 2; type 1 stenosis is exclusively located in the distal CBD, whereas type 2 stenosis is affects intra- and extrahepatic bile ducts. Diagnosis of biliary strictures with painless jaundice is also concerning for cholangiocarcinoma and pancreatic neoplasm, and these should be ruled out in the process of working up for an autoimmune cause. Steroid therapy is the initial treatment modality and many patients have good response. Changes in LFTs are best seen 5 and 10 days after therapy initiation and earlier initiation of therapy reduces risk of biliary cirrhosis. This case highlights the importance of laboratory and radiologic data in obtaining an accurate diagnosis.

Su1587 Accuracy of Probe-Based Confocal LASER Endomicroscopy (pCLE) in the Diagnosis of Biliary Strictures

Accurate diagnosis is essential for guiding appropriate therapy of patients with biliary strictures. Current modalities, including ERCP-guided biopsy and brush cytology have low sensitivity and variable accuracy. Probe-based confocal laser endomicroscopy (pCLE) is an innovative technique that allows for real-time optical pathology at the time of endoscopy. pCLE is safe and carries a sensitivity of 98% and negative predictive value of 97% for the diagnosis of malignant biliary strictures.

Su1589 Comparison Between Continuous Infusion and Intermittent Bolus Injection of Propofol for Deep Sedation During Endoscopic Retrograde Cholangiopancreatography

negative predictive value of 97% for the diagnosis of malignant biliary strictures. Aim: The objective of this study was to evaluate the role of probe-based confocal laser endomicroscopy in the real-life diagnosis of biliary strictures at the time of endoscopy. Methods: A retrospective review of all patients who underwent ERCP with pCLE of biliary strictures was performed between the years 2010 and 2014 at Mount Sinai Beth Israel Medical Center. The accuracy, sensitivity, specificity, positive predictive value, and negative predictive value were determined for brush cytology, forceps biopsy and pCLE. Results: To date, 36 patients have been identified who underwent ERCP with pCLE, brush cytology and biopsy for the workup of a biliary stricture where the final pathology was known. The diagnoses determined via pCLE, cytology, and biopsy were compared to the final diagnoses. The results of the accuracy, sensitivity, specificity, positive predictive value and negative predictive value are demonstrated in Table 1 below. Among the cases in this study, 53% were malignant and 47% were benign. Conclusion: pCLE can greatly aid in the accurate diagnosis of biliary strictures and thus can lead to improved management of patients when compared to the other diagnostic modalities. Thus pCLE may become the gold standard in the diagnosis of biliary malignancy.

Su1583 Pediatric Biopsy Forceps vs Spybite Forceps Comparison At the Diagnosis of Biliary Strictures: a Randomized Study

Su1583 Pediatric Biopsy Forceps vs Spybite Forceps Comparison At the Diagnosis of Biliary Strictures: a Randomized Study

SRM-Based quantification of malignant biliary stenosis biomarkers in human bile

The differential diagnosis of biliary stenosis is a critical problem for gastroenterologists. An early identification of malignant lesions would enable the rapid resort to surgical resection which currently represents the only potentially curative option. Unfortunately, the diagnostic value of all available methods (e.g. imaging technics, standard serum biomarkers) is limited by relatively poor accuracy and negative predictive value. Recently, our group and others highlighted new potential cancer biomarkers in bile by using comparative proteomic analysis. Nevertheless, to date, only a few candidates have been verified for their diagnostic performances in discriminating between malignant and non-malignant stenoses. In addition, no data have yet been collected on the simultaneous measurement of these proteins with the intent of evaluating the diagnostic interest of a panel of biomarkers. To overcome the limitation of classical verification tools and give a new impetus to the translation of bile biomarkers into clinical diagnostics, mass spectrometry-based quantification could represent a rapid and cost-effective opportunity thanks to its capacity for multiplexed, high-throughput analysis, combined with its analytical specificity and reliable quantification. Here we developed the first Selected Reaction Monitoring (SRM) assay for the multiplexed measurement of cancer biomarkers in human bile. For this purpose, 8 potential biomarker candidates previously highlighted by proteomic analysis were selected. Equal volumes of bile collected from patients presenting with malignant and non-malignant biliary stenosis were stacked on the top of a SDS-PAGE gel. Proteins were then digested in-gel with trypsin and proteotypic peptides of each candidate biomarker were quantified by nanoLC-SRM on a 5500-QTrap mass spectrometer (ABSciex) using heavy synthetic peptides as standards (PEPotecTM, Thermofisher). SRM data were finally analysed using Skyline software and manual validation. The developed assay proved to be valuable and reliable to quantify all the selected candidates. Moreover, the results confirmed the simultaneous overexpression of some of the proteins in bile samples from malignant stenoses. Overall, our data demonstrate the ability of SRM to quantify cancer biomarkers in human bile and emphasize the interest of using multiplexed SRM assays to assess the diagnostic potential of a panel of bile biomarkers in differentiating biliary stenoses. Work supported by the PRIME-XS consortium.

Su1144 Conventional Y Stent Versus Niti-S Large Cell D-Type (LCD) Stent in Bilateral Stent Placement for Advanced Hilar Malignancy

G A A b st ra ct s evidence-based consensus statements for the diagnosis of biliary strictures. Methods: Initial statements on the use of CLE for the characterization of indeterminate biliary strictures were developed by a single CLE expert based on the available clinical evidence. Those preliminary statements were edited and submitted by an external group of 16 GI physicians using a modified Delphi approach. After two rounds of votes based on relevant data, quality of the evidence and strength of recommendation, statements were validated if the threshold of agreement was higher than 75%. Results: Out of 9 proposed statements, 7 were validated and 3 rejected.CLE can be used to evaluate biliary strictures, and the probe can be delivered via a catheter or a cholangioscope. CLE is more accurate than ERCP with brush cytology and/or forceps biopsy in determining malignant or benign strictures, using established criteria. The accuracy of CLE in indeterminate biliary strictures may be decreased by prior presence of plastic stent. The Negative Predictive Value (NPV) of CLE is very high. The use of CLE can assist clinical decision-making such as excluding malignancy. CLE should be cited as a valuable tool for an increased diagnostic yield in official guidelines. The «black bands» that can be seen in pCLE images have been shown to be collagen fibrils that predictably increase in pathologic tissue. Conclusion: According to the panel of 16 physicians, given its very high accuracy, Confocal Laser Endomicroscopy has the potential to improve the current diagnostic algorithm of biliary strictures. At centers where expertise is available, Confocal Laser Endomicroscopy used during ERCP in the evaluation of biliary strictures should be considered as a standard practice complementary to conventional tissue sampling.