Indeterminate Biliary Stricture

Biliary obstruction results from diverse benign and malignant processes, and patients can present with acute or chronic signs and symptoms that vary greatly in severity ( Table 41.1 ). The nature of an obstruction is often immediately clear at the time of initial investigation, whereas at other times obstruction is readily apparent but the nature of the pathologic process remains uncertain. No single definition exists for the term “indeterminate stricture,” but it commonly refers to biliary strictures in patients in whom cross-sectional imaging is unrevealing, that is, without an associated mass lesion and without pathologic confirmation. Others describe the indeterminate lesion as one for which laboratory testing, imaging, and endoscopic retrograde cholangiopancreatography (ERCP) with cytology brushing fail to establish an etiology.

When biliary obstruction is identified, an efficient approach to early diagnostic testing and management is important for reduction in morbidity and guidance of definitive therapy. Untreated obstructive cholestasis of even moderate degree can culminate in secondary biliary cirrhosis within several months. In several studies patients with unresolved postcholecystectomy duct strictures developed secondary biliary cirrhosis in 15 to 62 months. Key steps in the assessment and management of patients with indeterminate biliary strictures include characterization of the pathogenesis of the stricture, relief of biliary obstruction, and/or definitive treatment of the pathologic process employing medical, endoscopic, percutaneous, or surgical means. Stricture characterization and relief of obstruction are not independent pursuits but are typically accomplished in unison. Stricture characterization is based on historical features, laboratory testing, noninvasive and invasive imaging, and the use of various tissue sampling methods ( Fig. 41.1 ).

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Algorithm for evaluation of jaundice and suspected biliary obstruction. See text for discussion. Biliary obstruction associated with pancreatic mass lesions with clinical or radiographic (CT) suspicion for autoimmune pancreatitis warrants further characterization and possibly steroid trials before entertaining surgery. CT, Computed tomography; Dx, diagnosis; E, extrahepatic; ERCP, endoscopic retrograde cholangiopancreatography; EUS, endoscopic ultrasonography; FNA, fine-needle aspiration; IH, intrahepatic; MRCP, magnetic resonance cholangiopancreatography; MRI, magnetic resonance imaging; US, ultrasonography.

(Adapted with permission from ASGE Standards of Practice Committee. An annotated algorithmic approach to malignant biliary obstruction. Gastrointest Endosc . 2001;53:849–852.)