Challenges in Diagnosing Biliary Stricture

Petros C. Benias, MD; David L. Carr-Locke, MD


February 27, 2012

Case Presentation

An 82-year-old Chinese man presented with a 2-week history of jaundice and weight loss of 8 lb. Upon further investigation, he reported acholic stools, pruritus, and persistent nausea but denied any abdominal pain and appeared comfortable overall. His medical history was significant for lung cancer 25 years ago that was treated with pneumonectomy and colorectal cancer 8 years ago that was treated with an anterior-posterior resection. He had a negative colonoscopy and PET scan approximately 5 years ago. He also reported a history of diabetes that was well controlled with oral hyperglycemic agents. The patient smoked for over 30 years but only occasionally used alcohol socially.

On presentation, the patient appeared jaundiced, with hepatomegaly and no abdominal tenderness. Laboratory values were as follows: alpha-fetoprotein, 1.7 ng/mL; carcinoembryonic antigen, 1 μg/L; aspartate aminotransferase, 116 U/L; alanine aminotransferase, 299 U/L; alkaline phosphatase; 481 U/L; and international normalized ratio, 1.

Initial endoscopic retrograde cholangiopancreatography (ERCP) was performed (Figures 1-3), and cytologic analysis of a fine-needle aspiration sample was nondiagnostic. The patient was evaluated for surgical resection because of high suspicion of biliary cancer. A transhepatic biliary drainage catheter was placed to facilitate intraoperative dissection.

The patient clinically decompensated because of cholangitis; therefore, a second ERCP was necessary for the placement of metal stents. During this ERCP, cholangioscopy was used to visualize the tumor. Again, intraductal biopsies were nondiagnostic.

The patient improved but developed signs of recurrent cholangitis 1 month later that necessitated repeated ERCP. This time, biliary confocal endomicroscopy was performed in addition to cholangioscopy (Figure 4). In vivo endomicroscopy showed areas that appeared abnormal. Specifically, loss of the normal reticular pattern was seen, with evidence of neovascularization with ectatic vessels. Biopsies supported the diagnosis of cholangiocarcinoma.

Figure 1. An endoscopic ultrasonogram of the distal common hepatic duct shows no obvious mass lesions.
Figure 2. An endoscopic ultrasonogram of the proximal common hepatic duct near bifurcation shows a suspicious mass.
Figure 3. An endoscopic retrograde cholangiopancreatography fluoroscopic image shows a possible hilar stenosis with intrahepatic dilatation.
Figure 4. Tortuous large vessels with black areas (indicating decreased uptake of fluorescein), loss of reticular pattern of thin epithelial bands, and villous or gland-like structures.


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