The recommendations provide guidance on the care of patients with extrahepatic and perihilar strictures, with a focus on diagnosis and drainage. Although some of the principles may apply to intrahepatic strictures, the guideline doesn’t specifically address them. The new guideline is considered separate from the 2015 ACG guideline related to primary sclerosing cholangitis.
“The appropriate diagnosis and management of biliary strictures is still a big clinical challenge and has important implications in endoscopic, surgical, and oncological decision-making,” co-author Jennifer Maranki, MD, a professor of medicine and director of endoscopy at Penn State Hershey Medical Center, said in an interview.
“We wanted to provide the best possible guidance to gastroenterologists based on the available body of literature, with key shifts in diagnosis and management based on currently available modalities and tools,” she said.
The guideline was published in the March issue of the American Journal of Gastroenterology.
The recommendations were developed by a diverse group of authors from across the United States in recognition of the potential influence of commercial and intellectual conflicts of interest. The panel used a systematic process that involved structured literature searches by librarians and independent appraisal of the quality of evidence by dedicated methodologists, the authors write.
Overall, the team outlined 11 recommendations and 12 key concepts. A strong recommendation was made when the benefits of the test or intervention clearly outweighed the potential disadvantages. A conditional recommendation was made when some uncertainty remained about the balance of benefits and harms. Key concepts address important clinical questions that lack adequate evidence to inform recommendations. They are based on indirect evidence and expert opinion.
Epidemiology and diagnosis
The burden of biliary strictures is difficult to estimate, owing to the lack of a specific administrative code. The estimated cost of caring for biliary disease in the United States is about $16.9 billion annually, although this figure includes costs associated with gallbladder disease, choledocholithiasis, and other (nonobstructive) biliary disorders, the authors write.
Among the 57,000 new cases of pancreatic cancer each year, at least 60% will cause obstructive jaundice, resulting in about 34,000 annual cases of malignant extrahepatic biliary stricture, the team notes. In addition, about 3,000 cases of malignant perihilar stricture are expected in the United States each year. Patients may also seek care for benign strictures associated with chronic pancreatitis, primary sclerosing cholangitis, autoimmune disease, and post-cholecystectomy injury.
Under the first key concept, the authors note that biliary strictures in adults are more likely to be malignant than benign, except in certain well-defined scenarios. This underscores the importance of having a high index of clinical suspicion during evaluation, they add.
In general, a definitive tissue diagnosis is necessary to guide oncologic and endoscopic care for most strictures that aren’t surgically resectable at the time of presentation. For patients with extrahepatic biliary stricture due to an apparent or suspected pancreatic mass, endoscopic ultrasound (EUS) with fine-needle sampling (aspiration or biopsy) is recommended over endoscopic retrograde cholangiopancreatography (ERCP) as the preferred method of evaluation for malignancy.
For patients with suspected malignant perihilar stricture, multimodality sampling is recommended over brush cytology alone at the time of the index ERCP.