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

Figures & data

Table 1 Differential Diagnosis – Clinical Presentation – Imaging Modalities And Tissue Acquisition Techniques In Patients With MDBO

Differential Diagnosis Of MDBO	Symptoms/Signs	Imaging Modalities	Tissue Acquisition	Differential Diagnosis With Benign Obstructions
Primary Cancer
Pancreatic cancer	Painless jaundice → icterus/pale stools/dark urine/pruritus Weight loss/anorexia Epigastric pain irradiation in the back (advanced disease Dyspepsia/early satiety → nausea/emesis New onset of glucose intolerance/diabetes Acute pancreatitis	CT > MRI/MRCP > TUS EUS	EUS FNA/FNB	Auto-immune pancreatitis Chronic pancreatitis Groove pancreatitis
Cholangiocarcinoma	Painless jaundice → icterus/pale stools/dark Urine/pruritus Right upper quadrant pain Weight loss/anorexia	MRI/MRCP > CT > TUS EUS	EUS FNA/FNB ERCP + brushing + forceps biopsies	PSC Ig G4 related cholangitis Eosinophilic cholangiopathy HIV related cholangiopathy
Ampullary cancer	Painless jaundice → icterus/pale stools/dark urine/pruritus Relapsing cholangitis/pancreatitis Weight loss/anorexia Dyspepsia/early satiety → nausea/emesis	MRI/MRCP > CT > TUS EUS	Duodenoscopy+ Biopsies EUS FNA/FNB	Benign ampullary neoplasms (adenoma, NET) HIV related cholangiopathy
Gallbladder cancer	Icterus/pale stools/dark urine/pruritus Right upper quadrant pain Weight loss/anorexia	CT > MRI/MRCP > TUS EUS	EUS FNA/FNB	Post-surgical benign strictures Ig G4 related disease
Metastatic cancer
Gastric/colon/breast/lung Melanoma/hepatocellular carcinoma	Symptoms related to primary disease	CT > MRI/MRCP > TUS EUS	EUS FNA/FNB	Tuberculosis

Abbreviations: MDBO, malignant distal biliary obstruction; CT, computed tomography; MRI, magnetic resonance imaging; TUS, transabdominal ultrasound; EUS, endoscopic ultrasound; FNA, fine-needle aspiration; FNB, fine-needle biopsy; PSC, primary sclerosing cholangitis; NET, neuroendocrine tumors.

Figure 1 A 69-year-old presented with abdominal pain and cholestasis. MRI showed a double duct sign and a suspected lesion at the papillary area (A), presenting an abnormal diffusion-weighted signal and suggestive of an ampulloma (B). ERCP revealed an ampullary mass (C) and standard biopsies were performed confirming the diagnosis of ampullary carcinoma. A 10mm USEMS of 6 cm of length is placed to relieve the obstruction (D, E).

Abbreviations: MRI, Magnetic resonance imaging; ERCP, Endoscopic retrograde cholangiopancreatography; USEMS, uncovered self-expandable metal stents.

Figure 2 A 67-year-old woman presenting with dyspepsia, weight loss and jaundice. CT showed a 6 cm mass in the head of the pancreas with vascular involvement (SMV > 270°, SMA >120%) compressing the distal CBD (A). Both EUS-FNB and ERCP with brushings confirmed non-resectable pancreatic adenocarcinoma (B). A 10mm USEMS 4cm was inserted to provide drainage before neoadjuvant chemotherapy (C).

Abbreviations: SMV, superior mesenteric vein; SMA, superior mesenteric artery; CBD, common bile duct; EUS-FNB, endoscopic ultrasound fine needle biopsy; ERCP, Endoscopic retrograde cholangiopancreatography; USEMS, uncovered self-expandable metal stent.

Figure 3 A 84-year-old woman presenting painless jaundice. TUS showed CBD and intrahepatic bile duct dilatation. MRI showed a suspected 22mm intraductal mass at the distal part of the CBD with an upstream dilatation (A). EUS-FNA confirmed an intraductal mass in the CBD suggestive of cholangiocarcinoma. ERCP revealed a long, irregular, distal biliary stricture (B); brushing and intraductal forceps biopsies confirmed the presence of malignant cells (C).

Abbreviations: TUS, transabdominal ultrasound; CBD, common bile duct; MRI, Magnetic resonance imaging; EUS-FNA, endoscopic ultrasound fine needle biopsy; ERCP, Endoscopic retrograde cholangiopancreatography.

Figure 4 Algorithm for the assessment of patients with biliary obstruction.

Abbreviations: TUS, transabdominal ultrasonography; CT, computed tomography; MRI, Magnetic resonance imaging; MDBO, malignant distal biliary obstruction; EUS, endoscopic ultrasound; FNA, fine needle aspiration; CCA, cholangiocarcinoma; PSC, primary sclerosing cholangitis; SOC, single-operator-cholangioscopy; IDUS, intraductal ultrasonography; CLE, confocal laser endomicroscopy; CA 19–9, Carbohydrate antigen 19–9.

Figure 5 Algorithm for the endoscopic management of patients with confirmed pancreaticobiliary malignancy.

Abbreviations: ERCP, Endoscopic retrograde cholangiopancreatography; SEMS, self-expandable metal stents; PTC, percutaneous cholangiography; EUS, endoscopic ultrasound.