Shyam Menon, MD, MRCP, MRCP(Gastro), PGDip (Epid), PGDip (Nutr), from the Department of Gastroenterology at the University Hospital Aintree in Liverpool, United Kingdom shares this VideoGIE case “Cholangioscopic evaluation of a sectoral biliary stricture.”
This video case demonstrates the application of a multidisciplinary approach to the management of a complex biliary stricture.
A patient was referred owing to a history of recurrent cholangitis after a laparoscopic cholecystectomy, with MRCP demonstrating a stricture in an aberrant right posterior sectoral duct. Because of weight loss and concern about malignancy, Spyglass cholangioscopy was performed to evaluate this stricture and obtain a tissue diagnosis.
At ERCP, cholangiography confirmed a right posterior duct inserting into the common hepatic duct with an associated stricture. No mucosal evidence of malignancy was noted on cholangioscopy, and biopsies from the stricture were benign. Despite dilatation and stenting of the stricture, the patient continued experiencing symptoms and underwent a right posterior segmental liver resection. Final pathology revealed focal active cholangitis and secondary biliary fibrosis.
Figure 1. Cholangiography demonstrating sectoral bile ducts. An aberrant right posterior duct is seen to insert separately into the common hepatic duct, adjacent to the cystic duct, with an associated stricture (block arrow).
Management of biliary strictures involves a cross-specialty approach, with high-quality non-invasive imaging and discussions on endoscopic and surgical management.
Although laparoscopic bile duct injuries are common, long term management in a symptomatic patient involves endoscopic and surgical management strategies. In this particular case, the exclusion of malignancy was important to plan surgical therapy. Cholangioscopy provided an opportunity to make an endoscopic and tissue diagnosis.
Cholangioscopy is an important tool for evaluating a complex biliary stricture and should be part of an endoscopist’s toolkit.
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