Current endoscopic approach to indeterminate biliary strictures

Figure 1 Fluoroscopic image during endoscopic retrograde cholangiopancreatography showing a hilar stricture with left intrahepatic biliary dilation. Endoscopic brushing was performed and routine cytology confirmed hilar cholangiocarcinoma.

Figure 2 Intraductal ultrasound showing bile duct mass and surrounding lymph nodes.

Figure 3 Endoscopic diagnosis and therapy for a bile duct mass missed on transabdominal imaging. A: Endoscopic ultrasound showing a bile duct mass that was missed by computed tomography and magnetic resonance imaging; B: Biliary dilation was present proximal to the stenosis; C: Endoscopic ultrasound-guided fine needle aspiration was performed and was diagnostic of cholangiocarcinoma; D: Endoscopic retrograde cholangioscopy was performed during the same session and cholangiography revealed distal biliary stricture; E, F: A fully-covered metal biliary stent was placed.

Figure 4 Endoscopic ultrasound evaluation of bile duct mass not seen on transabdominal imaging. A: Endoscopic ultrasound demonstrating the presence of bile duct mass; B: Endoscopic ultrasound-guided fine needle aspiration was diagnostic of cholangiocarcinoma

Figure 5 The “mother-baby” scope cholangioscopy system. The main disadvantage of this system is the requirement for two endoscopists to perform the procedure.

Figure 6 Spyglass single operator cholangioscopy system. A: SpyScope 10Fr access and delivery catheter; B: SpyGlass fiber optic probe; C: SpyBite biopsy forceps.

Figure 7 Single operator cholangioscopy used to obtain a diagnosis in a stricture with nondiagnostic cytology. A: Magnetic resonance cholangiopancreatography showing a long distal biliary stricture with proximal biliary dilation. Endoscopic retrograde cholangiopancreatography with brushing was non-diagnostic; B: SpyGlass cholangioscopy revealed a malignant-appearing ulcerated biliary stricture. Spybite biopsies confirmed cholangiocarcinoma.

Figure 8 SpyGlass cholangioscopy revealing a bile duct mass. This is indicative of cholangiocarcinoma.