Digestive Endoscopy| Volume 48, ISSUE 7, P765-770, July 2016

Download started.


Intraductal biopsies in indeterminate biliary stricture: Evaluation of histopathological criteria in fluoroscopy- vs. cholangioscopy guided technique

Published:April 08, 2016DOI:



      Differentiating malignancy from benign disease in indeterminate biliary stricture by imaging modalities is limited. Definite diagnosis relies on histopathological diagnosis.


      To assess accuracy of histopathological diagnosis of fluoroscopy-guided vs. cholangioscopy-directed intraductal biopsies in indeterminate biliary stricture.


      All patients with indeterminate biliary stricture and fluoroscopically (n = 68) or cholangioscopy-directed (working channel 2 mm, n = 38) biopsies were included. Histopathological results of biopsies were classified into inflammatory lesion (class 1), dysplasia/intraepithelial neoplasia (class 2) and malignancy (class 3) and results as well as macroscopic diagnosis were compared with final diagnosis.


      Sensitivity and specificity of fluoroscopy-guided vs. cholangioscopy-directed biopsies were 22.9% and 100% vs. 25.0% and 100% for class 1 + 2 vs. class 3 lesions, respectively. Sensitivity for class 1 vs. class 2 + 3 lesions was 45.7% (p = 0.044) vs. 58.3% (p = 0.214) for fluoroscopy-guided vs. cholangioscopy-directed biopsies, respectively, while specificity was 100% in both. There was no difference in size of the obtained sample (p = 0.992). True positive diagnosis rate increased with the number of biopsies taken (p = 0.028).


      Fluoroscopy-guided and cholangioscopy-directed intraductal biopsies are equally limited in establishing the diagnosis of malignancy in indeterminate biliary stricture.
      Categorizing dysplasia or intraepithelial neoplasia as malignancy increases sensitivity without decrease in specificity. By taking more biopsies, diagnostic yield is increased.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Digestive and Liver Disease
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Patel
        Nature Clinical Practice. Gastroenterology & Hepatology. 2006; 3: 33-42
        • Weber
        • Schmid
        • Prinz
        Diagnostic approaches for cholangiocarcinoma.
        World Journal of Gastroenterology. 2008; 14: 4131-4136
        • Kimura
        • Matsubayashi
        • Sasaki
        • et al.
        Factors affecting the yield of endoscopic transpapillary bile duct biopsy for the diagnosis of pancreatic head cancer.
        Pancreatology. 2013; 13: 524-529
        • Higashizawa
        • Tamada
        • Tomiyama
        • et al.
        Biliary guidewire facilitates bile duct biopsy and endoscopic drainage.
        Journal of Gastroenterology and Hepatology. 2002; 17: 332-336
        • Sugiyama
        • Atomi
        • Wada
        • et al.
        Endoscopic transpapillary bile duct biopsy without sphincterotomy for diagnosing biliary strictures: a prospective comparative study with bile and brush cytology.
        American Journal of Gastroenterology. 1996; 91: 465-467
        • Pugliese
        • Conlo
        • Nicolo
        • et al.
        Endoscopic retrograde forceps biopsy and brush cytology of biliary strictures: a prospective study.
        Gastrointestinal Endoscopy. 1995; 42: 520-526
        • Rösch
        • Hofrichter
        • Frimberger
        • et al.
        ERCP or EUS for tissue diagnosis of biliary strictures? A prospective comparative study.
        Gastrointestinal Endoscopy. 2004; 60: 390-396
        • Arnelo
        • von Seth
        • Bergquist
        Prospective evaluation of the clinical utility of single-operator peroral cholangioscopy in patients with primary sclerosing cholangitis.
        Endoscopy. 2015; 47: 696-702
        • Navaneethan
        • Hasan
        • Lourdusamy
        • et al.
        Single-operator cholangioscopy and targeted biopsies in the diagnosis of indeterminate biliary strictures: a systematic review.
        Gastrointestinal Endoscopy. 2015; 82 (608–14.e2)
        • Elsayes
        • Ellis
        • Elkhouly
        • et al.
        Diagnostic yield of percutaneous image-guided tissue biopsy of focal hepatic lesions in cancer patients: ten percent are not metastases from the primary malignancy.
        Cancer. 2011; 117: 4041-4048
        • Draganov
        • Chauhan
        • Wagh
        • et al.
        Diagnostic accuracy of conventional and cholangioscopy-guided sampling of indeterminate biliary lesions at the time of ERCP: a prospective, long-term follow-up study.
        Gastrointestinal Endoscopy. 2012; 75: 347-353
        • Farnik
        • Weigt
        • Malfertheiner
        • et al.
        A multicenter study on the role of direct retrograde cholangioscopy in patients with inconclusive endoscopic retrograde cholangiography.
        Endoscopy. 2014; 46: 16-21
        • Albert
        • Friedrich-Rust
        • Elhendawy
        • et al.
        Peroral cholangioscopy for diagnosis and therapy of biliary tract disease using an ultra-slim gastroscope.
        Endoscopy. 2011; 43: 1004-1009
        • Meves
        • Ell
        • Pohl
        Efficacy and safety of direct transnasal cholangioscopy with standard ultraslim endoscopes: results of a large cohort study.
        Gastrointestinal Endoscopy. 2014; 79: 88-94
        • Schlemper
        • Riddell
        • Kato
        • et al.
        The Vienna classification of gastrointestinal epithelial neoplasia.
        Gut. 2000; 47: 251-255
        • Domagk
        • Poremba
        • Dietl
        • et al.
        Endoscopic transpapillary biopsies and intraductal ultrasonography in the diagnostics of bile duct strictures: a prospective study.
        Gut. 2002; 51: 240-244
        • Navaneethan
        • Njei
        • Lourdusamy
        • et al.
        Comparative effectiveness of biliary brush cytology and intraductal biopsy for detection of malignant biliary strictures: a systematic review and meta-analysis.
        Gastrointestinal Endoscopy. 2015; 81: 168-176
        • Weber
        • von Weyhern
        • Fend
        • et al.
        Endoscopic transpapillary brush cytology and forceps biopsy in patients with hilar cholangiocarcinoma.
        World Journal of Gastroenterology. 2008; 14: 1097-1101
        • Hartman
        • Slivka
        • Giusto
        • et al.
        Tissue yield and diagnostic efficacy of fluoroscopic and cholangioscopic techniques to assess indeterminate biliary strictures.
        Clinical Gastroenterology and Hepatology. 2012; 10: 1042-1046
        • Chen
        • Parsi
        • Binmoeller
        • et al.
        Single-operator cholangioscopy in patients requiring evaluation of bile duct disease or therapy of biliary stones (with videos).
        Gastrointestinal Endoscopy. 2011; 74: 805-814
        • Nishikawa
        • Tsuyuguchi
        • Sakai
        • et al.
        Comparison of the diagnostic accuracy of peroral video-cholangioscopic visual findings and cholangioscopy-guided forceps biopsy findings for indeterminate biliary lesions: a prospective study.
        Gastrointestinal Endoscopy. 2013; 77: 219-226
        • Pohl
        • Meves
        • Mayer
        • et al.
        Prospective randomized comparison of short-access mother-baby cholangioscopy versus direct cholangioscopy with ultraslim gastroscopes.
        Gastrointestinal Endoscopy. 2013; 78: 609-616
        • Weilert
        • Bhat
        • Binmoeller
        • et al.
        EUS-FNA is superior to ERCP-based tissue sampling in suspected malignant biliary obstruction: results of a prospective, single-blind, comparative study.
        Gastrointestinal Endoscopy. 2014; 80: 97-104
        • Walter
        • Hartmann
        • Albert
        Indeterminate biliary stricture with suspicion for malignancy unmasked as eosinophilic cholangitis by cholangioscopy.
        Gastrointestinal Endoscopy. 2016;