Clinical approach to indeterminate biliary strictures: Clinical presentation, diagnosis, and workup

Figure 1 Fluoroscopy and Spyglass images of a patient with benign biliary stricture who previously underwent a liver transplant for primary sclerosing cholangitis/primary biliary cirrhosis. A: Fluoroscopy imaging during endoscopic retrograde cholangiopancreatography showing common bile duct stricture; B–D: Cholangioscopy images showing concentric stricture with scarring and minimal erythema.

Figure 2 Fluoroscopy images. A: A malignant biliary stricture; B: Intraductal brushings; C: Freehand biopsies.

Figure 3 Use of endoscopic ultrasound in evaluation of a biliary stricture. A: Linear array endoscopic ultrasound image of a pancreatic head mass, extending into the bile duct resulting in biliary stricture/obstruction and abutting the portal vein; B: Linear array endoscopic ultrasound image of a 22G fine needle biopsy of a pancreatic head mass.

Figure 4 Cholangioscopy images of malignant biliary strictures. A–D: Infiltrative stricture with finger like projections and friable, nodular elevated surface.

Figure 5 Biliary stricture biopsy. A: Microscopic examination (hematoxylin and eosin) reveals medium sized malignant cells arranged in clusters and single cell units. Tumor cells are diffusely distributed in an inflamed desmoplastic stroma; B: Immunostaining for CK7 performed on the biopsy specimen is positive in tumor cells with appropriate control.

Figure 6 Approach to indeterminate biliary strictures. ERCP: Endoscopic retrograde cholangiopancreatography; EUS: Endoscopic ultrasound; CT: Computerized tomography; MRI: Magnetic resonance imaging; MRCP: Magnetic resonance cholangiopancreatography; FISH: Fluorescence in situ hybridization; IDUS: Intraductal ultrasound; pCLE: Probe based confocal laser micro-endoscopy; CCA: Cholangiocarcinoma; IgG4: Immunoglobulin G4; CA 19-9: Carbohydrate antigen 19-9; FNA: Fine needle aspiration.