Ki-Yoon Kim, MD1, Franklin Tsai, MD1, Walter Coyle, MD1, Matthew Skinner, MD2 1Scripps Clinic, La Jolla, CA; 2Scripps Green - Scripps Clinic, San Diego, CA
Introduction: Traditionally, diagnosing etiology of biliary strictures has depended on ERCP based tissue acquisition such as brushing and or biopsy sampling. However, this approach has a suboptimal diagnostic accuracy. In recent years, digital single-operator cholangioscopy (DSOC) has emerged as a promising alternative with ability to perform biopsy of biliary strictures under direct endoscopic visualization. In our case, we report a diagnosis of hepatocellular carcinoma via DSOC in a patient with an indeterminate biliary stricture after non-diagnostic work up with traditional ERCP based techniques.
Case Description/Methods: 68-year-old man with decompensated alcoholic cirrhosis and hepatocellular carcinoma treated with trans-arterial chemoembolization (TACE) presented with obstructive jaundice. Vitals were normal. Exam revealed jaundice. Labs showed ALP of 350, total bilirubin of 6.0, direct bilirubin of 5.5, AST of 54, and ALT of 21. MRI multiphase with eovist showed left intrahepatic ductal dilation without a clear mass. Initial ERCP confirmed dilated left intrahepatic duct with a transition point at the hilum without any evidence of stones or a mass, consistent with a biliary stricture. The biliary stricture was brushed for cytology and fluorescence in situ hybridization (FISH). A plastic biliary stent was placed to decompress the biliary tree. The cytopathology revealed atypical epithelial cells but was nondiagnostic. The patient then underwent DSOC that revealed a mass at the hilum. Numerous tissue samples were obtained with a DSOC compatible biopsy forceps under direct endoscopic visualization (Video) and two plastic biliary stents were placed. Pathology revealed hepatocellular carcinoma and the patient was started on systemic chemotherapy.
Discussion: Biliary strictures may form due to benign diseases, inflammatory processes, malignancy, or local tumor invasion. Accurate diagnosis of indeterminate biliary strictures is imperative given the wide differential, but standard ERCP based brushing or biopsy has a suboptimal diagnostic yield of no more than 50%. In contrast, in two large multinational prospective studies, DSOC has demonstrated diagnostic accuracy of 86.5-87.1% based on direct cholangioscopic biopsy without a difference in procedure times, mean number of procedures, and adverse events when compared to standard ERCP techniques.
In conclusion, DSOC is an effective and safe intervention in diagnosing and managing patients with indeterminate biliary strictures.
Ki-Yoon Kim indicated no relevant financial relationships.
Franklin Tsai indicated no relevant financial relationships.
Walter Coyle indicated no relevant financial relationships.
Matthew Skinner indicated no relevant financial relationships.
Ki-Yoon Kim, MD1, Franklin Tsai, MD1, Walter Coyle, MD1, Matthew Skinner, MD2. P2794 - Seeing Is Believing - Cholangioscopic Diagnosis of Hepatocellular Carcinoma for an Indeterminate Biliary Stricture, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.