Indeterminate Biliary Strictures:Indeterminate Biliary Strictures:Diagnosis by ERCP, IDUS, Diagnosis by ERCP, IDUS,
Cholangioscopy, and Tissue SamplingCholangioscopy, and Tissue Sampling
Janak N. Shah, MD
Director of Pancreatic / Biliary Endoscopy
Interventional Endoscopy Services - California Pacific Medical Center
Director of Endoscopy- SFVAMC
Associate Clinical Professor of Medicine - UCSF
San Francisco, CA
What is an “indeterminate” biliary stricture ?
Biliary stricture without an identifiable cause (e.g. mass) on imaging (CT, MRI)
+/- prior negative tissue sampling
Endoscopist’s role in evaluating Endoscopist’s role in evaluating indeterminate strictures:indeterminate strictures:
Determine the cause: Benign or Malignant? Diff dx: cholangioCA, pancreatic CA, PSC, autoimmune (IGG4),
inflammatory (chronic pancreatitis), bile duct injury
Offer treatment options: benign - candidate for endo therapy? stent? malignant - resectable or unresectable? Stenting?
Available tools for evaluating Available tools for evaluating biliary strictures:biliary strictures:
ERCP
Cholangioscopy
Intraductal US (IDUS)
Endoscopic ultrasound (EUS)
ERCP in indeterminate stx:ERCP in indeterminate stx:
Assess presence / extent
tissue sampling
ERCP tissue sampling techniquesERCP tissue sampling techniques
Technique Sensitivity Technical aspects
bile aspirate cytology
27% (6-32%; 6 studies with n=351)* easy
retrieved biliary stent cytology
32% (11-79%; 6 studies with n=197)*easy; done at 2nd
procedure
brush cytology 42% (30-57%; 8 studies with n=578)* over-the-wire, easy
forceps biopsies 56% (43-81%; 6 studies with n=343)*more difficult;often requires
sphincterotomy
forceps + brushings55% (in same study brush alone 30%; bx
alone 43%)**
more difficult;often requires
sphincterotomy
* de Bellis M, GIE 2002** Jailwala J, GIE 2000
Improving yield at ERCP? Improving yield at ERCP? newer techniques in suspected malignancynewer techniques in suspected malignancy
Technique Method Utility
digital image analysis (DIA)
spectrophotometry to quantify DNA content14% sensitivity in cyto-
negative stx *
fluorescence in-situ hybridization (FISH)
fluorescently labeled DNA probes to detect loss / gain of chromosomes
62% sensitivity in cyto-negative stx *
optical coherence tomography (OCT)
catheter-based; cross-sectional, subsurface imaging (2mm) based on measuring
backscattered infrared light
1-2 abnl findings in 53-79% with cancer **
confocal endomicroscopy
catheter-based, in-vivo microscopic imagingabnl findings in 83%
with cancer ***
* Levy MJ, AJG 2008** Arvanitakis M, Endosc 2009*** Giovannini M, Surg Endosc 2011
Cholangioscopy for indeterminate Cholangioscopy for indeterminate stricturesstrictures
Visualization of stricture and ability for direct tissue sampling
Some studies suggest improved detection of malignancy over standard ERCP techniques (e.g. brushings): 92% vs. 66% (p=0.25) tumor detection among 53 PSC
pts with dominant strictures * 89% tumor detection (16 of 18) among 62 pts with
“indeterminate strictures”, majority with prior neg sampling **
* Tischendorf JJ, Endosc 2006 ** Shah RJ, Clin Gastroenterol Hepatol 2006
Cholangioscopy for stricturesCholangioscopy for strictures
Technology Pros Cons
mother-baby(fiberoptic / video)
allows biopsyreasonable image quality
2 operators2 processors
fragile, easily damaged
Single-operator fiberoptic disposable
allows biopsy4-way tip deflection
easier for proximal stx
inferior image quality compared to others
Direct ductoscopy with ultraslim gastroscopes
(+/- overtube, wire-guided, anchoring balloon
assistance)
widely availableallows biopsy
best imaging quality
technically challengingdifficult for prox. Stx
Nguyen NQ, Binmoeller KF, Shah JN. Tech Review GIE 2009
Cholangioscopy - Single-operator, Cholangioscopy - Single-operator, fiberoptic disposable systemfiberoptic disposable system
Cholangioscopy - Cholangioscopy - fiberoptic mother-babyfiberoptic mother-baby
Cholangioscopy - Cholangioscopy - video mother-babyvideo mother-baby
Cholangioscopy - ultraslim gastroscopeCholangioscopy - ultraslim gastroscope
IDUS for indeterminate stricturesIDUS for indeterminate strictures Catheter-based US probe, over-the-wire, 12-30 MHz Abnl features in suspected malignant stx:
hypoechoic, infiltrating mass notching or irregular outer border intraductal papillary growth suspicious LN
Improved tumor detection -- no direct tissue sampling malig dx accurately predicted in 89% among 34 PSC and 52 non-PSC
pts with indeterminate stx (higher in non-PSC); malign dx in 86% of 21 pts with negative cytology *
Retrospective blinded review of 30pts with indeterminate stx: benign vs. malign dx correct in 90% with IDUS vs. 67% with ERCP/cyto **
Other uses: assessing tumor extension for operative planning and resectability
* Levy MJ, AJG 2008** Vasquez-Sequeiros, GIE 2002
IDUSIDUS
EUS for indeterminate stricturesEUS for indeterminate strictures Bile duct (from ampulla to hilum) well visualized from
duodenum
Abnl features in suspected malignant stx: hypoechoic mass focal, irregular wall thickening intraductal papillary growth suspicious LN liver metastases and distant LN
Immediate tissue sampling / on-site analysis
Sensitivity of EUS-FNA for bile duct CA: Sensitivity of EUS-FNA for bile duct CA: indeterminate stx with prior negative samplingindeterminate stx with prior negative sampling
Study N Sensitivity
DeWittGIE 2006
24 pts 77%
EloubeidiClin Gast Hep 2004
28 pts 86%
Fritscher-RavensAJG 2004
44 pts 89%
EUS - biliary stricture
EUS-FNA of stricture
Summary: evaluating indeterminate biliary strictures
ductoscopyIDUS
EUS
ERCP- brush / bx- DIA / FISH
- OCT / confocal
Indeterminate biliary strictures:Approach at CPMC
EUS-FNA (with on-site cyto) +/- ERCP
diagnostic
ERCP if needed- biliary decompression- stent exchange- operative planning
non-diagnostic
ERCP- brushings / forceps bx- IDUS- consider cholangioscopy
Thank you...
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