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J R Soc Med. 2002 June; 95(6): 302–304.
PMCID: PMC1279916

Bile duct stricture: benign or malignant?

When bile duct strictures are identified at endoscopic retrograde cholangiopancreatography (ERCP), the distinction between benign and malignant can be challenging.

CASE HISTORY

A previously fit and well woman of 88 was referred for investigation of painless jaundice. There was no history of fevers, with or without rigors. She had not lost any weight and was teetotal. She had no relevant medical history and was not on any medications. General and systemic examination was unremarkable except for deep jaundice. Biochemically the picture was of obstructive jaundice (bilirubin 89 μmol/L, alkaline phosphatase 470 iu/L, alanine aminotransferase 42 iu/L, albumin 31 g/L). Abdominal ultrasound showed dilated intrahepatic ducts, dilatation of the common hepatic duct and a proximal common bile duct (CBD) 1.5 cm in diameter. Gallstones or bile duct stones were not seen and the pancreas was normal. An ERCP showed several calculi in the CBD. A sphincterotomy followed by a balloon trawl cleared all the stones. Her jaundice resolved and liver function tests became normal. Twelve months later the symptoms had returned and ultrasound findings were similar. At ERCP the CBD could not be cannulated; she was treated with intravenous antibiotics and her jaundice improved. A CT scan of the abdomen showed, in addition to dilated ducts, a short stricture at the lower CBD. On percutaneous transhepatic cholangiography multiple filling defects were seen in the common hepatic duct extending proximally into the intrahepatic ducts with narrowing of the distal CBD. The appearances were interpreted as extensive cholangiocarcinoma. Contrast was seen to flow into the duodenum (Figure 1). In view of the extent of disease and her age no further investigation or therapeutic action was planned. Over the next 2 years she had repeated episodes of jaundice which settled with intravenous antibiotics. As she continued to be well between admissions, the diagnosis of cholangiocarcinoma was doubted. A repeat ERCP showed a long segment of stricture in the mid CBD with filling of an apparent single duct superior to the stricture. An irregular tract was also noted emptying laterally into the hepatic flexure, suggestive of a biliary-colic fistula (Figure 2). A stent was placed across the stricture, which sealed the fistula. Seemingly, recurrent inflammation secondary to calculous disease had led to perforation into the colon.

Figure 1
Percutaneous transhepatic cholangiogram showing multiple filling defects in the common hepatic duct extending proximally into the intrahepatic ducts with narrowing of distal common bile duct
Figure 2
Cholangiogram showing an irregular tract with contrast emptying laterally into the hepatic flexure

COMMENT

Benign conditions that can mimic cholangiocarcinoma include localized strictures in primary sclerosing cholangitis, iatrogenic strictures1, suture granuloma2, amputation neuroma of the cystic duct3 and Mirizzi's syndrome with a high CA 19-94. Laboratory data are not always helpful in distinguishing benign from malignant. Cytological examination of bile obtained during cholangiography reveals typical malignant cells in only 25-50% of cholangiocarcinoma cases5,6. Serum tumour markers are of limited value. Carcinoembryonic antigen (CEA) is expressed in some bile duct cancer cells and an increased level in bile may be informative7. Fibronectin is another candidate marker in bile8.

Although the diagnosis of cholangiocarcinoma should be thought of in elderly patients, further investigations—particularly bile cytology along with bile CEA levels, brushings and dual phase CT or MR sequences—should be obtained before a confident diagnosis is made. If surgery is contraindicated by comorbidity, a biliary stent should be inserted during ERCP or percutaneous transhepatic cholangiography. A fistula from bile duct to colon has been reported only once before with bile duct calculi though it is a recognized complication of gallbladder cancer and of highly invasive bowel cancers.

References

1. Hadgis NS, Collier NA, Blumgart LH. Malignant masquerade of the hilum of the liver. Br J Surg 1985;72: 659-61 [PubMed]
2. Murphy JR, Shay SS, Moses FM, et al. Suture granuloma masquerading as malignancy of the biliary tract. Dig Dis Sci 1990;35: 1176-9 [PubMed]
3. Van Gulik TM, Brummelkamp WH, Lygidakis NJ. Traumatic neuroma giving rise to biliary obstruction after reconstructive surgery for iatrogenic lesions of the biliary tract—a report of three cases. Hepatogastroenterology 1989;36: 255-7 [PubMed]
4. Lin CL, Changchien CS, Chen YS. Mirizzi's syndrome with a high CA19-9 level mimicking cholangiocarcinoma. Am J Gastroenterol 1997;92: 2309-10 [PubMed]
5. Cohan RH, Illescas FF, Newman G, et al. Biliary cytodiagnosis. Bile sampling for cytology. Invest Radiol 1985;20: 177. [PubMed]
6. Harrell GS, Anderson MF, Berry PF. Cytologic bile examination in the diagnosis of biliary duct neoplastic strictures. Am J Roentgenol 1981;137: 1123. [PubMed]
7. Nakeeb A, Lipsett PA, Lillemoe KD, et al. Biliary carcinoembryonic antigen levels are a marker for cholangiocarcinoma. Am J Surg 1996;171: 147-52 [PubMed]
8. Korner T, Kropf J, Jaspersen D, et al. Fibronectin in human bile—a new marker for diagnosis of malignant bile duct processes? A pilot study. Z Gastroenterologie 1994;32: 87-90 [PubMed]

Articles from Journal of the Royal Society of Medicine are provided here courtesy of Royal Society of Medicine Press