Endoscopic transpapillary biopsies and intraductal ultrasonography in the diagnostics of bile duct strictures: a prospective study

Abstract

Background: In bile duct strictures, examination of wall layers by intraductal ultrasonography (IDUS) performed during endoscopic retrograde cholangiopancreatography (ERCP) may be diagnostically useful.

Methods: In the present study 60 patients with bile duct strictures of unknown aetiology were examined preoperatively by ERCP, including transpapillary biopsies and IDUS. Histopathological correlation was available for all patients undergoing these procedures.

Results: Postoperative diagnosis revealed 30 pancreatic carcinomas, 17 bile duct cancers, three gall bladder cancers, and 10 benign bile duct strictures. Using endoscopic transpapillary forceps biopsies (ETP), a correct preoperative diagnosis was achieved in 36 of 60 patients (60% of cases). Among the 50 malignant tumours, preoperative diagnosis by ETP revealed a sensitivity of 52% and a specificity of 100%. ERCP supplemented by IDUS allowed for correct preoperative diagnosis in 83% of cases (50 of 60 patients), which was significantly higher than the accuracy of ETP (p=0.008). By combining ETP with IDUS, a correct preoperative diagnosis was made in 59 of 60 patients resulting in an accuracy rate of 98%.

Conclusions: Because of its low accuracy, exclusive use of ETP is not a reliable diagnostic tool for a definitive preoperative diagnosis of bile duct strictures. By combining IDUS and ETP with ERCP however, preoperative diagnostic accuracy can be improved substantially.

Figures

Figure 1

Topographic allocation of the bile duct strictures under study (total n=60). Modified according to the criteria of Tompkins and colleagues.

Figure 2

A 67 year old male with pancreatic cancer. The patient initially presenting with obstructive jaundice was referred to our hospital for further diagnostics. (A) Endoscopic retrograde cholangiopancreatography suggested a malignant biliary obstruction. (B) Intraductal ultrasonography showed a suspected malignant mass (arrows) infiltrating the common bile duct. L, lumen of the common bile duct; HA, hepatic artery. (C) Histological analysis of a tissue specimen taken by transpapillary biopsy showed an adenocarcinoma with atypical clusters of stroma free epithelial cells (haematoxylin and eosin, ×200).

Figure 3

Intraductal ultrasonography. Benign stricture of the proximal common bile duct in a 46 year old female patient showing typical ultrasonographic characteristics of an inflammatory lesion: homogeneous echo rich mass with smooth margins (arrows).