ACG Issues New Clinical Guideline for Biliary Strictures

Carolyn Crist

March 09, 2023

The American College of Gastroenterology (ACG) issued a clinical guideline for the diagnosis and management of biliary strictures, or abnormal narrowing in the liver's ductal drainage system.

The recommendations provide guidance on the care of patients with extrahepatic and perihilar strictures, with a focus on diagnosis and drainage. Although some of the principles may apply to intrahepatic strictures, the guideline doesn't specifically address them. The new guideline is considered separate from the 2015 ACG guideline related to primary sclerosing cholangitis.

Dr Jennifer Maranki

"The appropriate diagnosis and management of biliary strictures is still a big clinical challenge and has important implications in endoscopic, surgical, and oncological decision-making," co-author Jennifer Maranki, MD, a professor of medicine and director of endoscopy at Penn State Hershey Medical Center, told Medscape Medical News.

"We wanted to provide the best possible guidance to gastroenterologists based on the available body of literature, with key shifts in diagnosis and management based on currently available modalities and tools," she said.

The guideline was published in the March issue of The American Journal of Gastroenterology.

The recommendations were developed by a diverse group of authors from across the United States in recognition of the potential influence of commercial and intellectual conflicts of interest. The panel used a systematic process that involved structured literature searches by librarians and independent appraisal of the quality of evidence by dedicated methodologists, the authors write.

Overall, the team outlined 11 recommendations and 12 key concepts. A strong recommendation was made when the benefits of the test or intervention clearly outweighed the potential disadvantages. A conditional recommendation was made when some uncertainty remained about the balance of benefits and harms. Key concepts address important clinical questions that lack adequate evidence to inform recommendations. They are based on indirect evidence and expert opinion.

Epidemiology and Diagnosis

The burden of biliary strictures is difficult to estimate, owing to the lack of a specific administrative code. The estimated cost of caring for biliary disease in the United States is about $16.9 billion annually, although this figure includes costs associated with gallbladder disease, choledocholithiasis, and other (nonobstructive) biliary disorders, the authors write.

Among the 57,000 new cases of pancreatic cancer each year, at least 60% will cause obstructive jaundice, resulting in about 34,000 annual cases of malignant extrahepatic biliary stricture, the team notes. In addition, about 3000 cases of malignant perihilar stricture are expected in the United States each year. Patients may also seek care for benign strictures associated with chronic pancreatitis, primary sclerosing cholangitis, autoimmune disease, and post-cholecystectomy injury.

Under the first key concept, the authors note that biliary strictures in adults are more likely to be malignant than benign, except in certain well-defined scenarios. This underscores the importance of having a high index of clinical suspicion during evaluation, they add.

In general, a definitive tissue diagnosis is necessary to guide oncologic and endoscopic care for most strictures that aren't surgically resectable at the time of presentation. For patients with extrahepatic biliary stricture due to an apparent or suspected pancreatic mass, endoscopic ultrasound (EUS) with fine-needle sampling (aspiration or biopsy) is recommended over endoscopic retrograde cholangiopancreatography (ERCP) as the preferred method of evaluation for malignancy.

For patients with suspected malignant perihilar stricture, multimodality sampling is recommended over brush cytology alone at the time of the index ERCP.

Guidance on Drainage

For management, the principal objective is to restore the physiologic flow of bile into the duodenum. Although there is wide variability in the difficulty and risk of drainage, depending on location and complexity, perihilar strictures are generally more challenging and are riskier to drain than extrahepatic strictures. The goals should be to alleviate symptoms, reduce serum bilirubin to a level such that chemotherapy can be safely administered, and optimize surgical outcomes.

For benign extrahepatic biliary strictures, ERCP is the preferred modality for durable treatment. Fully covered self-expanding metallic stent (SEMS) placement is recommended over multiple plastic stents to reduce the number of procedures required for long-term treatment.

For extrahepatic strictures due to resectable pancreatic cancer or cholangiocarcinoma, the authors recommend against routine preoperative biliary drainage. However, drainage is warranted for some patients, including those with acute cholangitis, severe pruritus, very high serum bilirubin levels, those undergoing neoadjuvant therapy, and those for whom surgery is delayed.

For malignant extrahepatic strictures that are unresectable or borderline resectable, SEMS placement is recommended over plastic stents. The evidence is insufficient to recommend for or against uncovered SEMS vs fully covered SEMS.

For perihilar strictures due to suspected malignancy, the evidence is insufficient to recommend for or against ERCP vs percutaneous transhepatic biliary drainage (PTBD). In addition, for malignant perihilar strictures, the evidence is insufficient to recommend for or against plastic stents vs uncovered SEMS.

For perihilar strictures due to cholangiocarcinoma in cases in which resection or transplantation is not possible, adjuvant endobiliary ablation plus plastic stent placement is recommended over plastic stent placement alone.

Overall, for patients with a biliary stricture for which ERCP is indicated but is unsuccessful or impossible, EUS-guided biliary access and drainage is recommended over PTBD, because it is associated with fewer adverse events. However, these interventional EUS procedures should be performed by an endoscopist with substantial experience.

Dr Victoria Gomez

"The workup of biliary strictures is challenging, invasive, and costly, requiring multiple diagnostic tools with highly variable yields," co-author Victoria Gomez, MD, associate professor of medicine and director of bariatric endoscopy at Mayo Clinic in Jacksonville, Florida, told Medscape Medical News.

"Providers caring for these patients must be up to date with the most current evidence so that they can make the safest and most well-informed decisions for their patients," she said. "These include considerations such as limiting the use of anesthesia, using tests that will result in the highest diagnostic yield, and providing effective therapies to decompress biliary obstruction."

Future Questions

Additional research is needed in several areas to strengthen recommendations and advance the field, the study authors write.

Dr Anna Tavakkoli

"Biliary strictures without an associated mass are a diagnostic challenge, and there are exciting opportunities to understand how new technologies, such as artificial intelligence, can be used to improve our assessment," co-author Anna Tavakkoli, MD, assistant professor of internal medicine in digestive and liver diseases at the University of Texas Southwestern Medical Center, Dallas, told Medscape Medical News.

"Also, we highlighted several controversies in the drainage of perihilar strictures, including whether to use ERCP vs percutaneous drainage, whether metallic or plastic stents are better, and what the optimal stent placement should be," she said. "Future multicenter studies are needed to address these key controversies."

Although fully covered SEMS placement remains effective for benign biliary strictures, multiple plastic stents may be a better alternative in some cases. Such cases include those in which the stricture is close to the hilum, those in which the gallbladder is intact and in which crossing the cystic duct orifice cannot be avoided, those in which a fully covered SEMS has previously migrated or was not well tolerated, and those in which stricture has recurred after removal of a fully covered SEMS.

"Comprehensive List"

"Overall, the authors have done a commendable job putting together a comprehensive list of recommendations that will invariably alter the practice of many therapeutic endoscopists for the diagnosis and management of biliary strictures," Matthew Fasullo, DO, an advanced endoscopy and gastroenterology fellow at New York University Medical Center, told Medscape Medical News.

Fasullo, who wasn't involved with the guideline, has published on advances in pathophysiology, diagnosis, and treatment for post-transplant biliary complications.

"The fact that...cholangioscopy-directed biopsies after an initial negative evaluation via ERCP reveal malignancy in 54% of cases underscores the need for best practice guidelines and supports advancements in diagnostics to confidently rule in or out cancer," he said.

"The movement toward multimodality sampling at the time of initial evaluation with a combination of brushing, fluoroscopy-directed biopsies, cholangioscopy-directed biopsies, and fluorescence in situ hybridization should become universally adopted in those with an ambiguous diagnosis," he added. "As technology continues to improve, next-generation sequencing will prove to be an invaluable adjunct to the current pathological evaluation."

The authors received no financial support for the guideline. One author has a consultant role for Takeda Pharmaceuticals and is an advisory board member role for Advarra. The other authors and Fasullo have disclosed no relevant financial relationships.

Am J Gastroenterol. Published March 1, 2023. Full text

Carolyn Crist is a health and medical journalist who reports on the latest studies for Medscape, MDedge, and WebMD.

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