Post written by Sooraj Tejaswi, MD, MSPH, FASGE, from the Division of Gastroenterology & Hepatology, University of California Davis School of Medicine, Sacramento, California.
This video case series describes and differentiates between the cholangioscopic features of benign dominant strictures and cholangiocarcinoma in PSC. It demonstrates that the morphologic features of cholangiocarcinoma in PSC is varied. It can be similar to that of non-PSC cholangiocarcinoma but can also present with morphologic features that are similar to intraductal papillary neoplasm of the bile duct (IPNB) and some that are unique to PSC.
Early diagnosis of cholangiocarcinoma is critical to improve outcomes, both in the presence and absence of PSC. While cholangioscopy has become an established diagnostic tool in the work up of suspected cholangiocarcinoma in the absence of PSC, its role in PSC is hampered by a dearth of knowledge of the cholangioscopic features of PSC. This is due to the rarity of the disease, hesitation among endoscopists in undertaking cholangioscopy in PSC due to the challenges of navigating the strictures and narrowed ducts, concerns about the potential risks of cholangioscopy in PSC such as cholangitis and mucosal trauma, and the lack of background knowledge of the cholangioscopic features of malignancy and benign disease in PSC. This video aims to fill the existing gap in the literature by contributing to the growth of video and image atlases, which other endoscopists can refer to. This can help increase the uptake of cholangioscopic evaluation of PSC, with the ultimate goal of early diagnosis of cholangiocarcinoma and better patient outcomes.
Cholangioscopy is safe and feasible in PSC in experienced hands, despite the stricturing disease. Visual diagnosis of cholangiocarcinoma can be accomplished in PSC. However, it is important to be cognizant of the unique features of cholangiocarcinoma in PSC. Targeted biopsies of suspicious findings, along with brush cytology and FISH analysis should be undertaken in all cases of suspected cholangiocarcinoma. Cholangioscopy in PSC significantly improves overall patient assessment compared to the approach of cross-sectional imaging with ERCP evaluation alone. Cholangioscopy can lead to an early diagnosis of cholangiocarcinoma and a better patient outcome.
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