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World J Gastroenterol. Sep 28, 2023; 29(36): 5198-5210
Published online Sep 28, 2023. doi: 10.3748/wjg.v29.i36.5198
Clinical approach to indeterminate biliary strictures: Clinical presentation, diagnosis, and workup
Sujani Yadlapati, Ramzi Mulki, Sergio A Sánchez-Luna, Ali M Ahmed, Kondal Rao Kyanam Kabir Baig, Shajan Peter
Sujani Yadlapati, Department of Gastroenterology and Hepatology, Indiana University Hospital, Indianapolis, IN 46202, USA
Ramzi Mulki, Sergio A Sánchez-Luna, Ali M Ahmed, Kondal Rao Kyanam Kabir Baig, Shajan Peter, Department of Gastroenterology and Hepatology, University of Alabama at Birmingham, Birmingham, AL 35294, USA
Author contributions: Yadlapati S and Mulki R contributed to the literature review and drafting the manuscript; Sánchez-Luna SA and Ahmed AM provided valuable assistance in manuscript preparation; Kyanam Kabir Baig KR and Peter S played a role in conceptualization and final review; Yadlapati S lead author responsible for conducting the, organizing the paper’s structure.
Conflict-of-interest statement: All the authors report no relevant conflicts of interest for this article.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: https://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Sujani Yadlapati, MD, Doctor, Department of Gastroenterology and Hepatology, Indiana University Hospital, 500 N University Blvd, Indianapolis, IN 46202, United States. syadlapati@iuhealth.org
Received: April 25, 2023
Peer-review started: April 25, 2023
First decision: July 9, 2023
Revised: July 23, 2023
Accepted: August 21, 2023
Article in press: August 21, 2023
Published online: September 28, 2023
Abstract

Despite advances in cross-sectional imaging and endoscopic technology, bile duct strictures remain a challenging clinical entity. It is crucial to make an early determination of benign or malignant nature of biliary strictures. Early diagnosis not only helps with further management but also minimizes mortality and morbidity associated with delayed diagnosis. Conventional imaging and endoscopic techniques, particularly endoscopic retrograde cholangiopancreatography (ERCP) and tissue sampling techniques play a key in establishing a diagnosis. Indeterminate biliary strictures (IDBSs) have no definite mass on imaging or absolute histopathological diagnosis and often warrant utilization of multiple diagnostics to ascertain an etiology. In this review, we discuss possible etiologies, clinical presentation, diagnosis, and management of IDBSs. Based on available data and expert opinion, we depict an evidence based diagnostic algorithm for management of IDBSs. Areas of focus include use of traditional tissue sampling techniques such as ERCP with brush cytology, intraductal biopsies, fluorescence in situ hybridization and flow cytometry. We also describe the role of endoscopic ultrasound (EUS)-guided fine needle aspiration and biopsies, cholangioscopy, confocal laser endomicroscopy, and intraductal EUS in management of IDBSs.

Keywords: Biliary strictures, Indeterminate strictures, Biliary sampling, Cholangioscopy, Benign strictures, Malignant strictures, Indeterminate biliary strictures

Core Tip: Despite advances in imaging and endoscopy, bile duct strictures remain challenging. Timely detection of malignant strictures is crucial. Conventional techniques play a crucial role in diagnosis, but indeterminate biliary strictures (IDBSs) require multiple diagnostic tools. This review discusses etiology, diagnosis, and workup of IDBSs, presenting an evidence-based algorithm focusing on traditional tissue sampling techniques and innovative technologies. The importance of future research is emphasized.