ASGE has developed a guideline to aid in quicker diagnosis of malignancy in biliary strictures of unknown cause to help avoid life-threatening issues such as infection and liver damage. 

Diagnosing malignancy in patients with biliary strictures – when the bile duct narrows and causes obstruction – as soon as possible is crucial for patient treatment and survival, according to the guideline to be published in the November 2023 issue of Gastrointestinal Endoscopy (GIE), ASGE’s monthly, peer-reviewed research journal. The five-year survival rate of cholangiocarcinoma (bile duct cancer) is about 10 percent. Diagnostic challenges include nonspecific imaging and few noninvasive alternative procedures. 

“Cholangiocarcinoma is a common biliary tract malignancy and the second-most common primary hepatic malignancy,” ASGE President Jennifer Christie, MD, FASGE, said. “Determining malignancy in biliary strictures oftentimes requires multiple time-consuming and costly procedures. This guideline provides evidence-based recommendations for the accurate diagnosis of malignancy using endoscopic methods.”

The guideline suggests the use of endoscopic retrograde cholangiopancreatography (ERCP) with fluoroscopic-guided biopsies and brush cytology, cholangioscopy and/or endoscopic ultrasound (EUS) for certain biliary strictures, accounting for such factors as diagnostic sensitivity, cost and adverse events.

ERCP uses an endoscope (an instrument with a lens) and X-rays to examine the bile and pancreatic ducts. During cholangioscopy, a probe and camera directly visualize and sample the bile duct. Cholangioscopy can help characterize benign versus malignant biliary stricture features, guide tissue sampling of these strictures and determine extent of involvement to direct treatment options available to the patient.

“ASGE has reviewed all available evidence and made patient-centered recommendations on how to best approach these tumors to make an accurate diagnosis, which will result in efficient patient care,” said Bashar J. Qumseya, MD, MPH, FASGE, corresponding author and Immediate Past Chair of the ASGE Standards of Practice Committee, which prepared the document based on the Grading of Recommendations Assessment, Development and Evaluation (GRADE) framework.

To diagnose malignancy in patients with biliary strictures of unknown cause undergoing ERCP, the guideline recommends:

• Fluoroscopic-guided biopsies – using imaging similar to an X-ray video – added to brush cytology – a diagnostic technique that takes samples – for any biliary stricture.
• Cholangioscopic-guided biopsies for nondistal strictures (not in the distal bile duct) in cases with a high likelihood of adequate drainage of the important liver segment or past nondiagnostic ERCP without cholangioscopy while at centers with expertise and readily available equipment.
• EUS for patients who have distal strictures or suspected spread to nearby lymph nodes, particularly with the ability to perform EUS during the same session as ERCP.

“Endoscopists should take into consideration their expertise and availability of these techniques to facilitate a diagnosis in the quickest and most efficient way,” lead author Larissa L. Fujii-Lau, MD, said. 

ASGE guidelines on aspects of gastroenterology clinical practice offer best-practice recommendations to help standardize care and enhance outcomes. They are reviewed for updates approximately every five years or when new data may impact a recommendation. View all ASGE guidelines.