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Endoscopy in Gastrointestinal Oncology - Slide 12 - J. Baillie - Distinguishing benign from malignant biliary strictures
Endoscopy in Gastrointestinal Oncology - Slide 12 - J. Baillie - Distinguishing benign from malignant biliary strictures
Endoscopy in Gastrointestinal Oncology - Slide 12 - J. Baillie - Distinguishing benign from malignant biliary strictures
Endoscopy in Gastrointestinal Oncology - Slide 12 - J. Baillie - Distinguishing benign from malignant biliary strictures
Endoscopy in Gastrointestinal Oncology - Slide 12 - J. Baillie - Distinguishing benign from malignant biliary strictures
Endoscopy in Gastrointestinal Oncology - Slide 12 - J. Baillie - Distinguishing benign from malignant biliary strictures
Endoscopy in Gastrointestinal Oncology - Slide 12 - J. Baillie - Distinguishing benign from malignant biliary strictures
Endoscopy in Gastrointestinal Oncology - Slide 12 - J. Baillie - Distinguishing benign from malignant biliary strictures
Endoscopy in Gastrointestinal Oncology - Slide 12 - J. Baillie - Distinguishing benign from malignant biliary strictures
Endoscopy in Gastrointestinal Oncology - Slide 12 - J. Baillie - Distinguishing benign from malignant biliary strictures
Endoscopy in Gastrointestinal Oncology - Slide 12 - J. Baillie - Distinguishing benign from malignant biliary strictures
Endoscopy in Gastrointestinal Oncology - Slide 12 - J. Baillie - Distinguishing benign from malignant biliary strictures
Endoscopy in Gastrointestinal Oncology - Slide 12 - J. Baillie - Distinguishing benign from malignant biliary strictures
Endoscopy in Gastrointestinal Oncology - Slide 12 - J. Baillie - Distinguishing benign from malignant biliary strictures
Endoscopy in Gastrointestinal Oncology - Slide 12 - J. Baillie - Distinguishing benign from malignant biliary strictures
Endoscopy in Gastrointestinal Oncology - Slide 12 - J. Baillie - Distinguishing benign from malignant biliary strictures
Endoscopy in Gastrointestinal Oncology - Slide 12 - J. Baillie - Distinguishing benign from malignant biliary strictures
Endoscopy in Gastrointestinal Oncology - Slide 12 - J. Baillie - Distinguishing benign from malignant biliary strictures
Endoscopy in Gastrointestinal Oncology - Slide 12 - J. Baillie - Distinguishing benign from malignant biliary strictures
Endoscopy in Gastrointestinal Oncology - Slide 12 - J. Baillie - Distinguishing benign from malignant biliary strictures
Endoscopy in Gastrointestinal Oncology - Slide 12 - J. Baillie - Distinguishing benign from malignant biliary strictures
Endoscopy in Gastrointestinal Oncology - Slide 12 - J. Baillie - Distinguishing benign from malignant biliary strictures
Endoscopy in Gastrointestinal Oncology - Slide 12 - J. Baillie - Distinguishing benign from malignant biliary strictures
Endoscopy in Gastrointestinal Oncology - Slide 12 - J. Baillie - Distinguishing benign from malignant biliary strictures
Endoscopy in Gastrointestinal Oncology - Slide 12 - J. Baillie - Distinguishing benign from malignant biliary strictures
Endoscopy in Gastrointestinal Oncology - Slide 12 - J. Baillie - Distinguishing benign from malignant biliary strictures
Endoscopy in Gastrointestinal Oncology - Slide 12 - J. Baillie - Distinguishing benign from malignant biliary strictures
Endoscopy in Gastrointestinal Oncology - Slide 12 - J. Baillie - Distinguishing benign from malignant biliary strictures
Endoscopy in Gastrointestinal Oncology - Slide 12 - J. Baillie - Distinguishing benign from malignant biliary strictures
Endoscopy in Gastrointestinal Oncology - Slide 12 - J. Baillie - Distinguishing benign from malignant biliary strictures
Endoscopy in Gastrointestinal Oncology - Slide 12 - J. Baillie - Distinguishing benign from malignant biliary strictures
Endoscopy in Gastrointestinal Oncology - Slide 12 - J. Baillie - Distinguishing benign from malignant biliary strictures
Endoscopy in Gastrointestinal Oncology - Slide 12 - J. Baillie - Distinguishing benign from malignant biliary strictures
Endoscopy in Gastrointestinal Oncology - Slide 12 - J. Baillie - Distinguishing benign from malignant biliary strictures
Endoscopy in Gastrointestinal Oncology - Slide 12 - J. Baillie - Distinguishing benign from malignant biliary strictures
Endoscopy in Gastrointestinal Oncology - Slide 12 - J. Baillie - Distinguishing benign from malignant biliary strictures
Endoscopy in Gastrointestinal Oncology - Slide 12 - J. Baillie - Distinguishing benign from malignant biliary strictures
Endoscopy in Gastrointestinal Oncology - Slide 12 - J. Baillie - Distinguishing benign from malignant biliary strictures
Endoscopy in Gastrointestinal Oncology - Slide 12 - J. Baillie - Distinguishing benign from malignant biliary strictures
Endoscopy in Gastrointestinal Oncology - Slide 12 - J. Baillie - Distinguishing benign from malignant biliary strictures
Endoscopy in Gastrointestinal Oncology - Slide 12 - J. Baillie - Distinguishing benign from malignant biliary strictures
Endoscopy in Gastrointestinal Oncology - Slide 12 - J. Baillie - Distinguishing benign from malignant biliary strictures
Endoscopy in Gastrointestinal Oncology - Slide 12 - J. Baillie - Distinguishing benign from malignant biliary strictures
Endoscopy in Gastrointestinal Oncology - Slide 12 - J. Baillie - Distinguishing benign from malignant biliary strictures
Endoscopy in Gastrointestinal Oncology - Slide 12 - J. Baillie - Distinguishing benign from malignant biliary strictures
Endoscopy in Gastrointestinal Oncology - Slide 12 - J. Baillie - Distinguishing benign from malignant biliary strictures
Endoscopy in Gastrointestinal Oncology - Slide 12 - J. Baillie - Distinguishing benign from malignant biliary strictures
Endoscopy in Gastrointestinal Oncology - Slide 12 - J. Baillie - Distinguishing benign from malignant biliary strictures
Endoscopy in Gastrointestinal Oncology - Slide 12 - J. Baillie - Distinguishing benign from malignant biliary strictures
Endoscopy in Gastrointestinal Oncology - Slide 12 - J. Baillie - Distinguishing benign from malignant biliary strictures
Endoscopy in Gastrointestinal Oncology - Slide 12 - J. Baillie - Distinguishing benign from malignant biliary strictures
Endoscopy in Gastrointestinal Oncology - Slide 12 - J. Baillie - Distinguishing benign from malignant biliary strictures
Endoscopy in Gastrointestinal Oncology - Slide 12 - J. Baillie - Distinguishing benign from malignant biliary strictures
Endoscopy in Gastrointestinal Oncology - Slide 12 - J. Baillie - Distinguishing benign from malignant biliary strictures
Endoscopy in Gastrointestinal Oncology - Slide 12 - J. Baillie - Distinguishing benign from malignant biliary strictures
Endoscopy in Gastrointestinal Oncology - Slide 12 - J. Baillie - Distinguishing benign from malignant biliary strictures
Endoscopy in Gastrointestinal Oncology - Slide 12 - J. Baillie - Distinguishing benign from malignant biliary strictures
Endoscopy in Gastrointestinal Oncology - Slide 12 - J. Baillie - Distinguishing benign from malignant biliary strictures
Endoscopy in Gastrointestinal Oncology - Slide 12 - J. Baillie - Distinguishing benign from malignant biliary strictures
Endoscopy in Gastrointestinal Oncology - Slide 12 - J. Baillie - Distinguishing benign from malignant biliary strictures
Endoscopy in Gastrointestinal Oncology - Slide 12 - J. Baillie - Distinguishing benign from malignant biliary strictures
Endoscopy in Gastrointestinal Oncology - Slide 12 - J. Baillie - Distinguishing benign from malignant biliary strictures
Endoscopy in Gastrointestinal Oncology - Slide 12 - J. Baillie - Distinguishing benign from malignant biliary strictures
Endoscopy in Gastrointestinal Oncology - Slide 12 - J. Baillie - Distinguishing benign from malignant biliary strictures
Endoscopy in Gastrointestinal Oncology - Slide 12 - J. Baillie - Distinguishing benign from malignant biliary strictures
Endoscopy in Gastrointestinal Oncology - Slide 12 - J. Baillie - Distinguishing benign from malignant biliary strictures
Endoscopy in Gastrointestinal Oncology - Slide 12 - J. Baillie - Distinguishing benign from malignant biliary strictures
Endoscopy in Gastrointestinal Oncology - Slide 12 - J. Baillie - Distinguishing benign from malignant biliary strictures
Endoscopy in Gastrointestinal Oncology - Slide 12 - J. Baillie - Distinguishing benign from malignant biliary strictures
Endoscopy in Gastrointestinal Oncology - Slide 12 - J. Baillie - Distinguishing benign from malignant biliary strictures
Endoscopy in Gastrointestinal Oncology - Slide 12 - J. Baillie - Distinguishing benign from malignant biliary strictures
Endoscopy in Gastrointestinal Oncology - Slide 12 - J. Baillie - Distinguishing benign from malignant biliary strictures
Endoscopy in Gastrointestinal Oncology - Slide 12 - J. Baillie - Distinguishing benign from malignant biliary strictures
Endoscopy in Gastrointestinal Oncology - Slide 12 - J. Baillie - Distinguishing benign from malignant biliary strictures
Endoscopy in Gastrointestinal Oncology - Slide 12 - J. Baillie - Distinguishing benign from malignant biliary strictures
Endoscopy in Gastrointestinal Oncology - Slide 12 - J. Baillie - Distinguishing benign from malignant biliary strictures
Endoscopy in Gastrointestinal Oncology - Slide 12 - J. Baillie - Distinguishing benign from malignant biliary strictures
Endoscopy in Gastrointestinal Oncology - Slide 12 - J. Baillie - Distinguishing benign from malignant biliary strictures
Endoscopy in Gastrointestinal Oncology - Slide 12 - J. Baillie - Distinguishing benign from malignant biliary strictures
Endoscopy in Gastrointestinal Oncology - Slide 12 - J. Baillie - Distinguishing benign from malignant biliary strictures
Endoscopy in Gastrointestinal Oncology - Slide 12 - J. Baillie - Distinguishing benign from malignant biliary strictures
Endoscopy in Gastrointestinal Oncology - Slide 12 - J. Baillie - Distinguishing benign from malignant biliary strictures
Endoscopy in Gastrointestinal Oncology - Slide 12 - J. Baillie - Distinguishing benign from malignant biliary strictures
Endoscopy in Gastrointestinal Oncology - Slide 12 - J. Baillie - Distinguishing benign from malignant biliary strictures
Endoscopy in Gastrointestinal Oncology - Slide 12 - J. Baillie - Distinguishing benign from malignant biliary strictures
Endoscopy in Gastrointestinal Oncology - Slide 12 - J. Baillie - Distinguishing benign from malignant biliary strictures
Endoscopy in Gastrointestinal Oncology - Slide 12 - J. Baillie - Distinguishing benign from malignant biliary strictures
Endoscopy in Gastrointestinal Oncology - Slide 12 - J. Baillie - Distinguishing benign from malignant biliary strictures
Endoscopy in Gastrointestinal Oncology - Slide 12 - J. Baillie - Distinguishing benign from malignant biliary strictures
Endoscopy in Gastrointestinal Oncology - Slide 12 - J. Baillie - Distinguishing benign from malignant biliary strictures
Endoscopy in Gastrointestinal Oncology - Slide 12 - J. Baillie - Distinguishing benign from malignant biliary strictures
Endoscopy in Gastrointestinal Oncology - Slide 12 - J. Baillie - Distinguishing benign from malignant biliary strictures
Endoscopy in Gastrointestinal Oncology - Slide 12 - J. Baillie - Distinguishing benign from malignant biliary strictures
Endoscopy in Gastrointestinal Oncology - Slide 12 - J. Baillie - Distinguishing benign from malignant biliary strictures
Endoscopy in Gastrointestinal Oncology - Slide 12 - J. Baillie - Distinguishing benign from malignant biliary strictures
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Endoscopy in Gastrointestinal Oncology - Slide 12 - J. Baillie - Distinguishing benign from malignant biliary strictures

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  • 1. John Baillie, MB ChB, FRCP, FACG, FASGE Wake Forest University Health Sciences Winston-Salem, North Carolina
  • 2.  
  • 3.  
  • 4.  
  • 5.  
  • 6.  
  • 7. VICTORIA INFIRMARY, GLASGOW, SCOTLAND
  • 8.  
  • 9. MINNEAPOLIS, MINNESOTA, USA
  • 10.  
  • 11. MIDDLESEX HOSPITAL, LONDON TOWER BRIDGE, LONDON
  • 12.  
  • 13. DUKE UNIVERSITY MEDICAL CENTER
  • 14.  
  • 15. WAKE FOREST UNIVERSITY HEALTH SCIENCES, WINSTON-SALEM, NORTH CAROLINA, USA
  • 16.  
  • 17. ERCP
  • 18. Managing Biliary Strictures
    • Presentation
    • Asymptomatic - often an incidental finding
  • 19. Managing Biliary Strictures
    • Presentation
    • Asymptomatic - often an incidental finding
    • Symptomatic - pain, fever, jaundice, elevated liver enzymes
  • 20. Managing Biliary Strictures
    • Presentation
    • Asymptomatic - often an incidental finding
    • Symptomatic - pain, fever, jaundice, elevated liver enzymes
    • The diagnosis is often suggested by the clinical situation.
  • 21. 33 year old man with longstanding ulcerative colitis
  • 22. Primary Sclerosing Cholangitis
  • 23. 40 yr old woman with fever and malaise after lap cholecystectomy
  • 24. Ischemic injury to R main hepatic duct from misplaced clip
  • 25. Ischemic injury to R main hepatic duct from misplaced clip
  • 26. 75 year old man with progressive painless jaundice and itching
  • 27. Mass at the biliary confluence: cholangiocarcinoma (Klatskin tumor)
  • 28. CLASSIFICATION OF KLATSKIN TUMORS
  • 29. Managing Biliary Strictures
    • Klatskin tumor – a disease of the elderly
  • 30. What is “elderly”?
  • 31. Biliary Strictures
    • Causes:
    • Benign (I)
    • >Post-surgical (cholecystectomy, liver resection, transplantation)
    • >Chronic pancreatitis
    • >Primary sclerosing cholangitis
    • > HIV cholangiopathy
    • >Mirizzi syndrome
    • >Irradiation
  • 32. Biliary Strictures
    • Causes:
    • Benign (II)
    • >Vasculitis
    • >Blunt trauma
    • >Tuberculosis
    • >Intra-arterial chemotherapy (FUDR)
    • >Choledochal cysts
    • >Oriental (recurrent pyogenic) cholangitis
    • >Hepatic pseudotumor
  • 33. Biliary Strictures
    • Causes:
    • Malignant
    • >Pancreatic adenocarcinoma
    • >Mucinous cystadenocarcinoma
    • >Ampullary adenocarcinoma
    • >Gallbladder carcinoma
    • >Cholangiocarcinoma
    • >Hepatoma
    • >Lymphoma and metastatic malignancy
  • 34. Managing Biliary Strictures
    • Investigation of Biliary Strictures :
    • Imaging Modalities
    • > Transabdominal ultrasound (TUS)
  • 35.  
  • 36. Managing Biliary Strictures
    • Investigation of Biliary Strictures :
    • Imaging Modalities
    • >Transabdominal ultrasound (TUS)
    • Good for biliary dilatation – may identify level of obstruction of extrahepatic bile duct. Sensitive for stones and some tumors. Less useful at hilum and beyond…Useful for inspecting the gallbladder for stones and masses…
  • 37. Managing Biliary Strictures
    • Investigation of Biliary Strictures :
    • Imaging Modalities
    • >Transabdominal ultrasound (TUS)
    • > Endoscopic ultrasound (EUS)
  • 38. Managing Biliary Strictures
    • Investigation of Biliary Strictures :
    • Imaging Modalities
    • >Endoscopic ultrasound (EUS)
    • Excellent views of the biliary tree from the hilum down, the gallbladder, the entire pancreas, the celiac plexus. Offers tissue acquisition for cytopathology through EUS-fine needle aspiration (FNA). Therapeutic potential includes direct bile duct and pancreatic puncture.
  • 39.  
  • 40.  
  • 41. mass mass EUS in malignancy EUS diagnosis and Whipple resection of 15mm pancreatic cancer missed by CT
  • 42.  
  • 43.  
  • 44.  
  • 45.  
  • 46.  
  • 47.  
  • 48.  
  • 49.  
  • 50. Managing Biliary Strictures
    • Investigation of Biliary Strictures :
    • Imaging Modalities
    • >Transabdominal ultrasound (TUS)
    • >Endoscopic ultrasound (EUS)
    • > Computed tomography (CT) scan
  • 51.  
  • 52. Managing Biliary Strictures
    • Investigation of Biliary Strictures :
    • Imaging Modalities
    • >Computed tomography (CT) scan:
    • Good for masses, vascular involvement in tumors, biliary and pancreatic ductal dilatation, lymphadenopathy, fluid collections, stones >5mm in diameter, metastases (e.g local, liver).
  • 53.  
  • 54.  
  • 55.  
  • 56. Managing Biliary Strictures
    • Investigation of Biliary Strictures :
    • Imaging Modalities
    • >Transabdominal ultrasound (TUS)
    • >Endoscopic ultrasound (EUS)
    • >Computed tomography (CT) scan
    • > Magnetic resonance cholangiopancreatography (MRCP)
  • 57.  
  • 58.  
  • 59.  
  • 60. Managing Biliary Strictures
    • Investigation of Biliary Strictures :
    • Imaging Modalities
    • >Magnetic resonance cholangiopancreatography (MRCP)
    • Good for fluid-filled structures (T2-weighted images) (biliary and pancreatic ducts, blood vessels, fluid collections), defines some masses better than CT, identifies some stones
  • 61. Managing Biliary Strictures
    • Investigation of Biliary Strictures :
    • Imaging Modalities
    • >Transabdominal ultrasound (TUS)
    • >Endoscopic ultrasound (EUS)
    • >Computed tomography (CT) scan
    • >Magnetic resonance cholangiopancreatography (MRCP)
    • > Percutaneous transhepatic cholangiography (PTC)
  • 62.  
  • 63.  
  • 64. Managing Biliary Strictures
    • Investigation of Biliary Strictures :
    • Imaging Modalities
    • >Percutaneous transhepatic cholangiography (PTC)
    • Helpful if endoscopic access problematic. May provide optimal bilateral access for drainage and stenting. PTC placed catheters uncomfortable for patient (drains) and prone to leakage and displacement. Risks include bleeding, bile leak. Tough access ducts if not dilated.
  • 65. Managing Biliary Strictures
    • Investigation of Biliary Strictures :
    • Imaging Modalities
    • >Transabdominal ultrasound (TUS)
    • >Endoscopic ultrasound (EUS)
    • >Computed tomography (CT) scan
    • >Magnetic resonance cholangiopancreatography (MRCP)
    • >Percutaneous transhepatic cholangiography (PTC)
    • > Endoscopic retrograde cholangiopancreatography (ERCP)
  • 66.  
  • 67. Managing Biliary Strictures
    • Investigation of Biliary Strictures :
    • Imaging Modalities
    • >Transabdominal ultrasound (TUS)
    • >Endoscopic ultrasound (EUS)
    • >Computed tomography (CT) scan
    • >Magnetic resonance cholangiopancreatography (MRCP)
    • >Percutaneous transhepatic cholangiography (PTC)
    • >Endoscopic retrograde cholangiopancreatography (ERCP)
    • >Intraductal ultrasound
  • 68.  
  • 69. Managing Biliary Strictures
    • Investigation of Biliary Strictures :
    • Imaging Modalities
    • > Intraductal ultrasound (IDUS) / choledochoscopy
    • IDUS may elucidate nature of a stricture (e.g. in PSC). Choledochoscopy used to be regarded as experimental, but has become widely available through SpyGlass™ technology. May be helpful in the characterization of strictures and to look for bile duct stones.
  • 70.  
  • 71. Confocal Microscopy
  • 72.  
  • 73.  
  • 74.  
  • 75. CYTOLOGY
  • 76. CYTOLOGY BRUSH
  • 77. Brush cytology: yield about 30%
  • 78. HOWELL NEEDLE, BIOPSY FORCEPS
  • 79. Needle core/biopsy: yield about 50-60%
  • 80.  
  • 81. F.I.S.H.
  • 82. F.I.S.H. Fluorescent In Situ Hybridization
  • 83.  
  • 84.  
  • 85. BANANA CHROMOSOMES
  • 86.  
  • 87.  
  • 88.  
  • 89. PROTEOMICS
  • 90. Markers in Pancreatic Cancer
    • Mic-1 (macrophage inhibitory cytokine 1)
    • 90% of patients with pancreatic CA had Mic-1 levels > 2 SD above the mean for healthy controls.
    • Mic-1 and CA19-9 showed similar sensitivity for distinguishing CP from CA
    Courtesy of Dr Michelle Anderson, MD
  • 91. Positive MIC-1 Staining
  • 92. Diagnosis of Malignancy
    • Clinical course (“give cancer a chance”..)
    • CT- or EUS-guided fine needle aspiration biopsy
    • Endoscopic (or radiologic) brush cytology
    • Endoscopic (or radiologic) needle core (Howell needle) or direct biopsy
    • “ Salvage” cytology
    • Flow cytometry
    • Fluorescent in-situ hybridization (FISH)
    • Proteomics (cell surface antigens)
    • Serologic markers: CEA, CA19-9, etc
    • PET/CT scanning
  • 93. Diagnosis of Malignancy in Biliary Strictures
    • Clinical course (“give cancer a chance”..)
    • CT- or EUS-guided fine needle aspiration biopsy
    • Endoscopic (or radiologic) brush cytology
    • Endoscopic (or radiologic) needle core (Howell needle) or direct biopsy
    • “ Salvage” cytology
    • Flow cytometry ∞
    • Fluorescent in-situ hybridization (FISH) ∞
    • Proteomics (cell surface antigens) ∞
    • Serologic markers: CEA, CA19-9, etc
    • PET/CT scanning
    • ∞ = expensive
  • 94. Diagnosis of Malignancy in Biliary Strictures
    • Clinical course (“give cancer a chance”..)
    • CT- or EUS-guided fine needle aspiration biopsy
    • Endoscopic (or radiologic) brush cytology
    • Endoscopic (or radiologic) needle core (Howell needle) or direct biopsy
    • “ Salvage” cytology
    • Flow cytometry ∞
    • Fluorescent in-situ hybridization (FISH) ∞
    • Proteomics (cell surface antigens) ∞
    • Serologic markers: CEA, CA19-9, etc
    • PET/CT scanning •• Confocal Microscopy
    • ∞ = expensive
  • 95.  

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