Biliary strictures are frequently encountered in interventional endoscopy. Their etiological diagnosis may be complicated 1 . Endoscopic ultrasound (EUS) guided biopsies, brush cytology, and wire-guided biopsies allow a diagnosis in most cases. Single-operator cholangioscopy (SOC) has radically changed the diagnostic approach, allowing visualization of the lesion, endoscopic characterization, and targeted biopsies 2 .
We report the case of a 71-year-old woman with a history of endometrial adenocarcinoma, with muscular and bone recurrence 4 years after treatment. She developed a sudden jaundice without any other clinical signs. A magnetic resonance cholangiopancreatography found a circumferential parietal thickening of the main bile duct with dilatation of the intrahepatic bile ducts ( Fig. 1 ). We decided to perform an EUS, which showed extensive cholangitis in the middle part of the bile duct with circumferential thickening of the bile duct mucosa. A 22 G needle biopsy was performed. Endoscopic retrograde cholangiopancreatography (ERCP) was then performed ( Fig. 2 ) with SOC, which showed that the strictured area was indeed a fibrous stenosis with anarchic vascularization ( Video 1 ).
Fig. 1.
Biliary magnetic resonance cholangiopancreatography imaging (MRCP) showing the main bile duct stricture with dilatation of the intrahepatic bile ducts. a MRCP sequence showing the biliary stricture (red arrow) and biliary dilatation. b Three-dimensional reconstruction of the biliary system showing the biliary stenosis (red arrow).
Fig. 2.
Retrograde cholangiography showing the different stages of the endoscopic retrograde cholangiopancreatography procedure. a Retrograde cholangiography showing the stricture of the main bile duct (black arrow). b Retrograde cholangiography with single-operator cholangioscopy (black arrow). c Retrograde cholangiography with wire-guided forceps (black arrow). d Placement of three plastic biliary stents.
Video 1 Endoscopic retrograde cholangiopancreatography and single-operator cholangioscopy for the diagnosis of indeterminate biliary stenosis and drainage with three plastic stents.
Biopsies were taken with forceps. Brush cytology and wire-guided biopsies were also performed. The procedure was completed with the placement of three plastic stents (one 15 cm and 8.5 Fr stent in the left bile duct; one 12 cm and 8.5 Fr stent and one 12 cm and 7 Fr stent in the right intrahepatic bile ducts). Histological examination found carcinomatous cells (mutated p53, PAX8 +), which were presumed to be metastasis of gynecological origin ( Fig. 3 ).
Fig. 3.
Biopsies of the main bile duct under single-operator cholangioscopy. a Normal biliary epithelium (black arrow) and neoplastic cells (red arrows) with hematoxylin-eosin stain (magnification × 200). b Neoplastic cells of gynecological origin with immunohistochemistry stain (PAX 8).
The use of SOC allows a finer analysis of indeterminate biliary stenosis. The presence of aberrant vascularization seems to be correlated with the neoplastic nature of the lesion 3 . SOC therefore allows macroscopic analysis of the lesion and targeted biopsies, probably making biliary sampling less random 4 5 .
Endoscopy_UCTN_Code_TTT_1AR_2AB
Acknowledgement
This work was supported by French state funds managed within the “Plan Investissements d’Avenir” and by the ANR (reference ANR-10-IAHU-02).
Footnotes
Competing interests The authors declare that they have no conflict of interest.
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References
- 1.Bowlus C L, Olson K A, Gershwin M E. Evaluation of indeterminate biliary strictures. Nat Rev Gastroenterol Hepatol. 2016;13:28–37. doi: 10.1038/nrgastro.2015.182. [DOI] [PubMed] [Google Scholar]
- 2.Gerges C, Beyna T, Tang R SY et al. Digital single-operator peroral cholangioscopy-guided biopsy sampling versus ERCP-guided brushing for indeterminate biliary strictures: a prospective, randomized, multicenter trial (with video) Gastrointest Endosc. 2020;91:1105–1113. doi: 10.1016/j.gie.2019.11.025. [DOI] [PubMed] [Google Scholar]
- 3.Robles-Medranda C, Oleas R, Sánchez-Carriel M et al. Vascularity can distinguish neoplastic from non-neoplastic bile duct lesions during digital single-operator cholangioscopy. Gastrointest Endosc. 2021;93:935–941. doi: 10.1016/j.gie.2020.07.025. [DOI] [PubMed] [Google Scholar]
- 4.Angsuwatcharakon P, Kulpatcharapong S, Moon J H. Consensus guidelines on the role of cholangioscopy to diagnose indeterminate biliary stricture. HPB (Oxford) 2021;24:17–19. doi: 10.1016/j.hpb.2021.05.005. [DOI] [PubMed] [Google Scholar]
- 5.Almadi M A, Itoi T, Moon J H et al. Using single-operator cholangioscopy for endoscopic evaluation of indeterminate biliary strictures: results from a large multinational registry. Endoscopy. 2020;52:574–582. doi: 10.1055/a-1135-8980. [DOI] [PubMed] [Google Scholar]