Diagnosis and Management of Biliary Strictures
- Biliary strictures in adults are more likely to be malignant than benign except in certain well-defined scenarios.
- In asymptomatic or minimally symptomatic patients with an extrahepatic biliary stricture due to an apparent or suspected pancreatic mass, we suggest single-session EUS and ERCP over ERCP alone for concurrent diagnosis and drainage.
- In patients with a suspected malignant perihilar stricture due to cholangiocarcinoma, EUS-FNA/B and percutaneous biopsy of the primary lesion (perihilar stricture or mass) should be avoided. Instead, intraductal sampling should be favored. EUS-FNA/B (or percutaneous biopsy) should only be performed to sample associated lymphadenopathy.
- If the etiology of a biliary stricture remains uncertain despite ERCP with multimodality intraductal sampling, additional diagnostic options exist and can be selectively deployed according to clinical context, stricture characteristics, and resource availability.
- An extrahepatic biliary stricture due to a benign condition should be treated for 12 months when using MPSs and for at least 6 months when using fcSEMSs, although some evidence suggests that 12 months of fcSEMS therapy is advantageous. When aiming for 12-month fcSEMS dwell time, stent exchange at the 6-month mark should be considered to reduce the risk of embedment.
- In patients with a benign biliary stricture and gallbladder in situ, endoscopists should consider treatment with MPSs instead of fcSEMSs if the cystic duct orifice cannot be avoided by the metallic prosthesis because of a possible increased risk of acute cholecystitis.
- A diagnosis of malignancy should be confirmed before placement of an uncovered SEMS (uSEMS) across a biliary stricture.
- In patients with a malignant extrahepatic biliary stricture who are potential candidates for pancreaticoduodenectomy and undergo uSEMS placement, we suggest placing the proximal (upstream) end of the prosthesis at least 1.5 cm below the biliary confluence.
- In patients with obstructive jaundice due to a malignant perihilar stricture who are otherwise asymptomatic and who have declined or are not candidates for additional treatment, palliative drainage is not mandatory and should be decided on an individual case basis.
- When ERCP is pursued to diagnose and treat perihilar strictures, it should be performed by endoscopists with sufficient training and/or experience in advanced biliary endoscopy. High-quality ERCP in patients with a perihilar stricture includes preprocedure review of available cross-sectional imaging, careful intraprocedural use of contrast injection and fluoroscopy, and administration of antibiotics when there is concern for slow or incomplete drainage of contrast from opacified bile ducts.
- In patients with a perihilar stricture, hepatobiliary drainage should be pursued in a volumetric sectorial fashion and not in terms of unilateral vs bilateral drainage. The technical goal is to drain >50% of the nonatrophic liver, with each sector contributing roughly one-third of the liver's volume.
- If SEMS is chosen for drainage of a malignant perihilar stricture, an effective drainage strategy using PS should be proven first.
Diagnosis and Management of Biliary Strictures
American College of Gastroenterology
March 1, 2023
Country of Publication
A biliary stricture is an abnormal narrowing in the ductal drainage system of the liver that can result in clinically and physiologically relevant obstruction to the flow of bile. The most common and ominous etiology is malignancy, underscoring the importance of a high index of suspicion in the evaluation of this condition. The goals of care in patients with a biliary stricture are confirming or excluding malignancy (diagnosis) and reestablishing flow of bile to the duodenum (drainage); the approach to diagnosis and drainage varies according to anatomic location (extrahepatic vs perihilar). For extrahepatic strictures, endoscopic ultrasound-guided tissue acquisition is highly accurate and has become the diagnostic mainstay. In contrast, the diagnosis of perihilar strictures remains a challenge. Similarly, the drainage of extrahepatic strictures tends to be more straightforward and safer and less controversial than that of perihilar strictures. Recent evidence has provided some clarity in multiple important areas pertaining to biliary strictures, whereas several remaining controversies require additional research. The goal of this guideline is to provide practicing clinicians with the most evidence-based guidance on the approach to patients with extrahepatic and perihilar strictures, focusing on diagnosis and drainage.
Male, Female, Adult, Older adult
Health Care Settings
Ambulatory, Outpatient, Operating and recovery room
Nurse, nurse practitioner, physician, physician assistant
D001659 - Biliary Tract
Elmunzer, B. Joseph MD, MSc1; Maranki, Jennifer L. MD, MSc2; Gómez, Victoria MD3; Tavakkoli, Anna MD, MSc4,5; Sauer, Bryan G. MD, MSc, FACG6; Limketkai, Berkeley N. MD, PhD, FACG7; Brennan, Emily A. MLIS8; Attridge, Elaine M. MLS9; Brigham, Tara J. MLIS, AHIP10; Wang, Andrew Y. MD6. ACG Clinical Guideline: Diagnosis and Management of Biliary Strictures. The American Journal of Gastroenterology 118(3):p 405-426, March 2023. | DOI: 10.14309/ajg.0000000000002190