Shyam Menon, MD, MRCP, MRCP(Gastro), PGDip(Epid), PGDip(Nutr Med) and colleagues present this video case from the VideoGIE section, “Immune-mediated cholangiopathy.”
This video case describes the clinical journey of a patient who presented with weight loss, jaundice, and a biliary stricture at the liver hilum. Cholangioscopy was performed with intent to evaluate this stricture and acquire a tissue diagnosis prior to definitive management. Cholangioscopy revealed a short segment of abnormal looking mucosa at the liver hilum with the rest of the bile duct being unremarkable. Biopsies from this area demonstrated a predominatly lymphopasmacytic infiltrate with no evidence of malignancy. Following initiation of steroid therapy, the patient’s clinical symptoms improved with a complete resolution of jaundice and an interval ERCP confirmed resolution of the hilar stricture.
We feel that this video highlights the diagnostic challenges and uncertainties associated with the evaluation of a hilar stricture. As there was no mass lesion on cross-sectional imaging, we felt that cholangioscopy would enable a thorough evaluation of the stricture and facilitate tissue acquisition. Autoimmune cholangiopathy can present as hilar strictures and must be distinguished from malignancy. Cholangioscopy allowed this distinction to be made.
The evaluation of a hilar stricture requires a thorough discussion of available diagnostic tools and careful pre-procedure planning in a multi-disciplinary setting. Cholangioscopy must be available as part of a therapeutic endoscopist’s armamentarium.
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