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Biliary stricture — Clinical Guidelines

Overview

Biliary strictures involve narrowing of the bile ducts, often complicating conditions like post-surgical anastomotic strictures, primary sclerosing cholangitis, or malignancies, leading to bile obstruction and potential liver complications. 1 4

Diagnosis

Initial Evaluation: MRI/MRCP recommended for comprehensive imaging 1.

Tumor Markers: Limited utility alone for diagnosis 1.

Biopsy: Intraductal biopsies used for etiology but interpretative agreement among pathologists is fair to moderate 3.

Interventional Imaging: ERCP with cholangiography often employed for detailed assessment 1 4.

Management

First-Line Treatments:

- Endoscopic Approaches: Stenting (metal stents preferred for palliation) 1 4 10. - Percutaneous Procedures: Bilioplasty for strictures post-OLT 8.

Adjunctive Treatments:

- Radiofrequency Ablation (RFA): Combined with stent placement for potential improved stent patency in malignant strictures 5. - Combined Therapies: Two-step approach combining radiology and endoscopy for complex strictures 7.

Special Populations

Post-OLT Patients: Interventional radiology effective for biliary stricture management 8.

Benign Strictures: Metallic stents show satisfactory long-term patency in selected patients 10.

Key Recommendations

Use MRI/MRCP for initial evaluation of biliary strictures (Evidence: Moderate) 1.

Employ metal stents for palliation in malignant strictures (Evidence: Moderate) 1 10.

Consider radiofrequency ablation combined with stent placement to enhance stent patency in malignant biliary strictures (Evidence: Weak) 5.

Interventional radiology should be considered as a first-line treatment for biliary strictures following orthotopic liver transplantation (Evidence: Moderate) 8.

For benign recurrent strictures unresponsive to other treatments, metallic stents may be a satisfactory long-term solution (Evidence: Moderate) 10.

Intraductal biopsies are useful but require careful interpretation due to variability in pathologist agreement (Evidence: Weak) 3.

References

1 Gadour E, Crinò SF, Spadaccini M, Facciorusso A. Diagnostic and therapeutic strategies for biliary strictures: a comparison of ACG, ESGE, and ASGE guidelines. Expert review of gastroenterology & hepatology 2026. link 2 Inoue T, Kutsumi H, Ibusuki M, Yoneda M. Feasibility of balloon-based endobiliary radiofrequency ablation under cholangioscopy guidance in a swine model. Scientific reports 2021. link 3 Liu YJ, Rogers J, Liu YZ, Gui X, Jalikis F, Koch L et al.. Interobserver agreement in pathologic evaluation of bile duct biopsies. Human pathology 2021. link 4 Nakai Y, Isayama H, Wang HP, Rerknimitr R, Khor C, Yasuda I et al.. International consensus statements for endoscopic management of distal biliary stricture. Journal of gastroenterology and hepatology 2020. link 5 Sofi AA, Khan MA, Das A, Sachdev M, Khuder S, Nawras A et al.. Radiofrequency ablation combined with biliary stent placement versus stent placement alone for malignant biliary strictures: a systematic review and meta-analysis. Gastrointestinal endoscopy 2018. link 6 . Medical Devices; Gastroenterology-Urology Devices; Classification of the Metallic Biliary Stent System for Benign Strictures. Final order. Federal register 2016. link 7 Curcio G, Traina M, Miraglia R, Tarantino I, Barresi L, Granata A et al.. Endoscopy after radiology: two-step combined therapy for biliary stricture after Roux-en-Y hepaticojejunostomy. Digestive endoscopy : official journal of the Japan Gastroenterological Endoscopy Society 2012. link 8 Righi D, Cesarani F, Muraro E, Gazzera C, Salizzoni M, Gandini G. Role of interventional radiology in the treatment of biliary strictures following orthotopic liver transplantation. Cardiovascular and interventional radiology 2002. link 9 Khong PL, John PR. Percutaneous retrieval of a fractured biliary guidewire from a reduced liver graft. Pediatric radiology 1997. link 10 Maccioni F, Rossi M, Salvatori FM, Ricci P, Bezzi M, Rossi P. Metallic stents in benign biliary strictures: three-year follow-up. Cardiovascular and interventional radiology 1992. link

Biliary stricture