Pacheco-Cassamá J, Monteiro S, Silva J. Two scopes, one mission: An integrated approach of endoscopic retrograde cholangiopancreatography and endoscopic ultrasound to biliary strictures. World J Gastroenterol 2025; 31(45): 112436 [DOI: 10.3748/wjg.v31.i45.112436]
Corresponding Author of This Article
Josimar Pacheco-Cassamá, MD, Department of Gastroenterology, Unidade Local de Saúde do Tâmega e Sousa, Avenida do Hospital Padre Américo, 210, Penafiel 4560-136, Porto, Portugal. josimar.pachecocassama@gmail.com
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Gastroenterology & Hepatology
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Review
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This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Dec 7, 2025 (publication date) through Dec 6, 2025
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World Journal of Gastroenterology
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1007-9327
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Baishideng Publishing Group Inc, 7041 Koll Center Parkway, Suite 160, Pleasanton, CA 94566, USA
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Pacheco-Cassamá J, Monteiro S, Silva J. Two scopes, one mission: An integrated approach of endoscopic retrograde cholangiopancreatography and endoscopic ultrasound to biliary strictures. World J Gastroenterol 2025; 31(45): 112436 [DOI: 10.3748/wjg.v31.i45.112436]
World J Gastroenterol. Dec 7, 2025; 31(45): 112436 Published online Dec 7, 2025. doi: 10.3748/wjg.v31.i45.112436
Two scopes, one mission: An integrated approach of endoscopic retrograde cholangiopancreatography and endoscopic ultrasound to biliary strictures
Josimar Pacheco-Cassamá, Sara Monteiro, Jorge Silva
Josimar Pacheco-Cassamá, Sara Monteiro, Jorge Silva, Department of Gastroenterology, Unidade Local de Saúde do Tâmega e Sousa, Penafiel 4560-136, Porto, Portugal
Author contributions: Pacheco-Cassamá J performed the literature research and drafted the manuscript; Monteiro S reviewed the manuscript and provided critical input on its intellectual content and structure; Silva J critically revised the manuscript; All authors have read and approved the final manuscript.
Conflict-of-interest statement: The authors have no conflicts of interest to declare.
Open Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: https://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Josimar Pacheco-Cassamá, MD, Department of Gastroenterology, Unidade Local de Saúde do Tâmega e Sousa, Avenida do Hospital Padre Américo, 210, Penafiel 4560-136, Porto, Portugal. josimar.pachecocassama@gmail.com
Received: July 27, 2025 Revised: September 1, 2025 Accepted: October 13, 2025 Published online: December 7, 2025 Processing time: 129 Days and 15.4 Hours
Abstract
The management of biliary strictures is challenging both diagnostically and therapeutically, requiring a combination of advanced endoscopic techniques. Endoscopic retrograde cholangiopancreatography (ERCP) remains the gold standard for therapeutic interventions, including biliary drainage, stent placement, and tissue sampling via brush cytology or forceps biopsy. However, ERCP may not be suitable for obtaining deep tissue samples and can lead to complications such as post-ERCP pancreatitis. Endoscopic ultrasound (EUS) has emerged as a complementary modality, offering high-resolution imaging of the biliary tree and adjacent structures. EUS-guided fine-needle aspiration (EUS-FNA) and EUS-guided fine-needle biopsy (EUS-FNB) improve diagnostic accuracy, especially where ERCP-based sampling is inconclusive. Additionally, EUS plays an increasingly therapeutic role in the management of biliary strictures, particularly through EUS-guided biliary drainage, which is an effective alternative when ERCP fails due to surgically altered anatomy or inaccessible strictures. This review discusses the use of EUS and ERCP in the management of biliary strictures, highlighting their strengths and limitations, and proposes a stepwise and integrated approach. This strategy may enhance diagnostic precision and expand therapeutic options, particularly in indeterminate or complex clinical scenarios.
Core Tip: The optimal diagnostic and therapeutic approach to the management of biliary strictures utilizes endoscopic ultrasound and endoscopic retrograde cholangiopancreatography. This review highlights existing evidence to guide clinicians in the management of biliary strictures, focusing on the benefits of performing both procedures in the same session. Two algorithms are presented to standardize patient care by personalizing the approach based on individual patient factors and institutional expertise.
