Diagnosis and Medical Management of Biliary Strictures

Abstract Biliary strictures are a relatively rare condition characterized by narrowing of the intrahepatic or extrahepatic bile ducts. Though biliary strictures are most commonly malignant in etiology, both benign and malignant strictures are associated with significant morbidity and mortality. The diagnosis of an indeterminate biliary stricture is often challenging and requires a comprehensive workup, including laboratory testing, biochemical markers, and imaging and endoscopy, with the primary aims of differentiating malignant versus benign biliary disease and identifying the location, length, and extent of the stricture. A wide range of imaging modalities can be employed in doing so, including ultrasound, computed tomography, magnetic resonance imaging, or magnetic resonance cholangiopancreatography. Tissue sampling is often required during the workup of indeterminate biliary strictures and is most feasibly obtained through endoscopy. Diagnosis of indeterminant biliary strictures should be prompt to prevent long-term sequelae of the disease. Once diagnosed, the treatment of biliary strictures is guided by the etiology, location, and severity of the stricture. Benign biliary strictures have been historically treated with balloon dilation and stenting. These procedures remain mainstays in treatment, but additional therapeutic advances including radiofrequency ablation, laser stricturotomy, and magnetic compression anastomoses have emerged as novel, potentially beneficial adjuncts. In malignant biliary strictures, the resectability of malignancy is the primary factor determining treatment. Surgical management for resectable malignancies causing malignant biliary strictures remains the gold standard treatment approach. For unresectable malignant biliary strictures, the goal shifts to adequately draining the biliary tree to palliate the patient using similar treatment approaches as benign biliary strictures. With advancing endoscopic, percutaneous, and surgical techniques, standard-of-care diagnostic and treatment approaches are likely to continue to evolve to further optimize long-term outcomes.