Still elusive: Developments in the accurate diagnosis of indeterminate biliary strictures

Abstract

Indeterminate biliary strictures pose a significant diagnostic dilemma for gastroenterologists. Despite advances in endoscopic techniques and instruments, it is difficult to differentiate between benign and malignant pathology. A positive histological diagnosis is always preferred prior to high risk hepatobiliary surgery, or to inform other types of therapy. Endoscopic retrograde cholangiopancreatography with brushings has low sensitivity and despite significant improvements in instruments there is still an unacceptably high false negative rate. Other methods such as endoscopic ultrasound and cholangioscopy have improved diagnostic quality. In this review we explore the techniques available to aid accurate diagnosis of indeterminate biliary strictures and obtain accurate histology to facilitate clinical management.

Keywords: Indeterminate biliary stricture; Benign biliary stricture; Malignant biliary stricture; Endoscopic retrograde cholangiopancreatography; Endoscopic ultrasound; Primary sclerosing cholangitis

Core Tip: Indeterminate biliary strictures remain a diagnostic challenge, despite significant advances in imaging and endoscopic techniques; there remains a risk of false reassurance of absence of cancer or over-treatment of benign disease. While various guidelines have been developed to help clinicians in their diagnostic approach, these strictures need to be assessed on an individual basis and often with the help of a multi-disciplinary team. Enhanced optical modalities, possibly combined with rapid molecular analysis and the use of artificial intelligence, may lead to significant improvements in the next decade.