Diagnosis & Management of Biliary Strictures

Benign vs. malignant classification, diagnostic workup, and evidence-based management — ACG 2023 Guidelines.

Classification

Benign vs malignant, location

Biliary Strictures: A Critical Distinction

Differentiating benign from malignant biliary strictures is one of GI's most challenging clinical problems. Malignant strictures must not be missed; benign ones must not be over-treated.

Benign Etiologies

Post-surgical (choledochojejunostomy, liver transplant)

Chronic pancreatitis (distal CBD)

Primary sclerosing cholangitis (PSC)

IgG4-related sclerosing cholangitis (IgG4-SC)

Mirizzi syndrome

Biliary stone disease

Malignant Etiologies

Cholangiocarcinoma (CCA) — most common malignant cause

Pancreatic adenocarcinoma (distal stricture)

Gallbladder cancer

Hepatocellular carcinoma with bile duct involvement

Metastatic disease to porta hepatis

Ampullary carcinoma

Bismuth Classification (Hilar Strictures)

Type IBelow confluence; hepatic ducts free

Type IIReaches confluence but does not involve it

Type IIIInvolves confluence (IIIa: right; IIIb: left)

Type IVInvolves both right and left ducts separately

Elmunzer BJ et al. ACG Clinical Guideline: Diagnosis and Management of Biliary Strictures. Am J Gastroenterol. 2023.