Early Diagnosis And Management Of Malignant Distal Biliary Obstruction: A Review On Current Recommendations And Guidelines

Abstract

Malignant biliary obstruction is a challenging condition, requiring a multimodal approach for both diagnosis and treatment. Pancreatic adenocarcinoma and cholangiocarcinoma are the leading causes of malignant distal biliary obstruction. Early diagnosis is difficult to establish as biliary obstruction can be the first presentation of the underlying disease, which can already be at an advanced stage. Consequently, the majority of patients (70%) with malignant distal biliary obstruction are unresectable at the time of diagnosis. The association of clinical findings, laboratory tests, imaging, and endoscopic modalities may help in identifying the underlying cause. Novel endoscopic techniques such as cholangioscopy, intraductal ultrasonography, or confocal laser endomicroscopy have been developed with promising results, but are not used in routine clinical practice. As the number of patients with malignant distal biliary obstruction who will undergo curative surgery is limited, endoscopy has a crucial role in palliation, to relieve biliary obstruction. According to the last European guidelines published in the management of biliary obstruction, self-expandable metal stents have a central place in biliary drainage compared to plastic stents. Endoscopic ultrasound has evolved impressively in the last decades. When standard techniques of biliary cannulation by endoscopic retrograde cholangiopancreatography fail, endoscopic ultrasound-guided biliary drainage is a good option compared to percutaneous drainage.

Keywords:

• distal biliary stricture
• pancreaticobiliary malignancy
• preoperative biliary drainage
• self-expandable metal stent
• palliative biliary drainage

Abbreviations

MDBO, malignant distal biliary obstruction; CCA, cholangiocarcinoma; GB, gallbladder; dCCA, distal cholangiocarcinoma; ALP, alkaline phosphatases; GGT, gamma glutamyl transferase; ALT, alanine aminotransferase; AST, aspartate aminotransferase; CA 19-9, Carbohydrate antigen 19-9; CEA, carcinoembryonic antigen; TUS, transabdominal ultrasonography; CT, computed tomography; MRI, magnetic resonance imaging; MRCP, magnetic resonance cholangiopancreatography; EGD, esophagogastroduodenoscopy; ERCP, endoscopic retrograde cholangiopancreatography; EUS, endoscopic ultrasound; FNA, fine-needle aspiration; PET/CT, positron emission tomography/computed tomography; CE EUS, contrast-enhanced endoscopic ultrasound; FNB, fine needle-biopsy; ESGE, European society of gastrointestinal endoscopy; AGA, American gastroenterological association; PPV, positive predictive value; NPV, negative predictive value; IDUS, intraductal ultrasonography; CLE, confocal laser endomicroscopy; SOCP, single operator cholangiopancreatoscopy; FSOCP, fibro-optic single operator cholangiopancreatoscopy; DSOCP, Digital single operator cholangiopancreatoscopy; DPCS, Direct peroral cholangioscopy system; PBD, preoperative biliary drainage; RCT, randomized control study; SEMS, self-expandable metal stent; PS, plastic stent; FCSEMS, fully covered self-expandable metal stent; USEMS, uncovered self-expandable metal stent; PTC, percutaneous cholangiography; EUS-BD, endoscopic ultrasound – biliary drainage; HG, hepaticogastrostomy; CD, choledochoduodenostomy; RFA, radiofrequency ablation; PDT, photodynamic therapy.

Disclosure

The authors report no conflicts of interest in this work.