Benign Biliary Strictures

Endoscopic Retrograde Cholangiopancreatography: Deciphering the Black and White

Endoscopic Retrograde Cholangiopancreatography (ERCP) remains the conventional method of imaging the pancreatic and biliary tree and is performed by direct injection of iodinated contrast material via the major papilla. This diagnostic procedure gained popularity in the 1970s and subsequently paved way for ERCP guided interventions such as sphincterotomy, stone retrieval and stent placement. Currently, therapeutic ERCP is more widespread than diagnostic ERCP primarily due to the availability of noninvasive imaging. Nevertheless, more than half a million ERCPs are performed annually in the United States and radiologists need to be comfortable interpreting them. The following review will familiarize the reader with the imaging appearances of biliary and pancreatic disorders on conventional ERCP, and elaborate on therapeutic ERCP with illustrative examples.

Noninvasive Imaging of the Biliary Tree for the Interventional Radiologist

Patients with suspected biliary tract disease often pose a diagnostic challenge to the clinician and radiologist. Although advances across all imaging modalities, including ultrasound, computed tomography, and magnetic resonance, have improved our diagnostic accuracy for biliary disease, many of the imaging findings remain nonspecific. Recognition of key imaging findings combined with knowledge and understanding of the clinical context is essential to piecing together a diagnosis and guiding management for patients with biliary disease. Although there is a wide range of biliary pathology, interventional radiologists most commonly play a role in the management of biliary obstruction and leak.

Adult bile duct strictures: role of MR imaging and MR cholangiopancreatography in characterization

Bile duct strictures in adults are secondary to a wide spectrum of benign and malignant pathologic conditions. Benign causes of bile duct strictures include iatrogenic causes, acute or chronic pancreatitis, choledocholithiasis, primary sclerosing cholangitis, IgG4-related sclerosing cholangitis, liver transplantation, recurrent pyogenic cholangitis, Mirizzi syndrome, acquired immunodeficiency syndrome cholangiopathy, and sphincter of Oddi dysfunction. Malignant causes include cholangiocarcinoma, pancreatic adenocarcinoma, and periampullary carcinomas. Rare causes include biliary inflammatory pseudotumor, gallbladder carcinoma, hepatocellular carcinoma, metastases to bile ducts, and extrinsic bile duct compression secondary to periportal or peripancreatic lymphadenopathy. Contrast material-enhanced magnetic resonance (MR) imaging with MR cholangiopancreatography is extremely helpful in the noninvasive evaluation of patients with obstructive jaundice, an obstructive pattern of liver function, or incidentally detected biliary duct dilatation. Some of these conditions may show characteristic findings at MR imaging-MR cholangiopancreatography that help in making a definitive diagnosis. Although endoscopic retrograde cholangiopancreatography with tissue biopsy or surgery is needed for the definitive diagnosis of many of these strictures, certain MR imaging characteristics of the narrowed segment (eg, thickened wall, long-segment involvement, asymmetry, indistinct outer margin, luminal irregularity, hyperenhancement relative to the liver parenchyma) may favor a malignant cause. Awareness of the various causes of bile duct strictures in adults and familiarity with their appearances at MR imaging-MR cholangiopancreatography are important for accurate diagnosis and optimal patient management.

Benign biliary strictures: a current comprehensive clinical and imaging review

OBJECTIVE

There is a wide spectrum of nonneoplastic causes of biliary stricture that can pose a significant challenge to clinicians and radiologists. Imaging plays a key role in differentiating benign from malignant strictures, defining the extent, and directing the biopsy. We describe the salient clinical and imaging manifestations of benign biliary strictures that will help radiologists to accurately diagnose these entities.

CONCLUSION

Accurate diagnosis and management are based on correlating imaging findings with epidemiologic, clinical, and laboratory data. Cross-sectional imaging modalities permit precise localization of the site and length of the segment involved, thereby serving as a road map to surgery, and permit exclusion of underlying malignancy.

Laparoscopic hepaticojejunostomy for biliary strictures: the experience of 10 patients

Hepaticojejunostomy is performed to reestablish bilioenteric continuity. During a 5-year period between July 1998 and July 2003, the authors attempted hepaticojejunostomy by a total laparoscopic approach in 10 patients with benign stricture disorders of the extrahepatic biliary tree. Six of these patients had type 1 (extrahepatic, fusiform) choledochal cyst and presented with pain, fever, and jaundice. Four of the patients had iatrogenic biliary strictures after cholecystectomy (2 patients after laparoscopic cholecystectomy and 2 patients after open cholecystectomy). These patients had a variable presentation 1 to 3 weeks after the primary procedure, with peritonitis and/or cholangitis or only progressive jaundice. For nine of the patients (90%), the procedure was completed entirely laparoscopically. The mean operative time was 326.6 min for the patients with choledochal cysts and 268 min for the patients with iatrogenic strictures. One patient with stricture after open cholecystectomy underwent conversion to an open repair because of severe anatomic distortion and fibrosis. Four patients drained bile postoperatively for 5 to 7 days. One patient with iatrogenic biliary stricture after open cholecystectomy required open revision of the anastomosis 18 months after laparoscopic hepaticojejunostomy because of recurrent cholangitis. The remaining eight patients (80%) were doing well a mean follow-up period of 3.1 years (range, 3 months to 5 years). Total laparoscopic hepaticojejunostomy is feasible for a select group of patients, but requires advanced laparoscopic skills, including intracorporeal suturing. It must be attempted only in centers well versed in advanced laparoscopic surgery.