John Baillie, MB ChB, FRCP, FACG, FASGE Wake Forest University Health Sciences Winston-Salem, North Carolina
 
 
 
 
 
VICTORIA INFIRMARY, GLASGOW, SCOTLAND
 
MINNEAPOLIS, MINNESOTA, USA
 
MIDDLESEX HOSPITAL, LONDON TOWER BRIDGE, LONDON
 
DUKE UNIVERSITY MEDICAL CENTER
 
WAKE FOREST UNIVERSITY HEALTH SCIENCES, WINSTON-SALEM, NORTH CAROLINA, USA
 
ERCP
Managing Biliary Strictures <ul><li>Presentation </li></ul><ul><li>Asymptomatic  - often an incidental finding </li></ul>
Managing Biliary Strictures <ul><li>Presentation </li></ul><ul><li>Asymptomatic  - often an incidental finding </li></ul><...
Managing Biliary Strictures <ul><li>Presentation </li></ul><ul><li>Asymptomatic  - often an incidental finding </li></ul><...
33 year old man with longstanding ulcerative colitis
Primary Sclerosing Cholangitis
40 yr old woman with fever and malaise after lap cholecystectomy
Ischemic injury to R main hepatic duct from misplaced clip
Ischemic injury to R main hepatic duct from misplaced clip
75 year old man with progressive painless jaundice and itching
Mass at the biliary confluence: cholangiocarcinoma (Klatskin tumor)
CLASSIFICATION OF KLATSKIN TUMORS
Managing Biliary Strictures <ul><li>Klatskin tumor – a disease of the elderly </li></ul>
What is “elderly”?
Biliary Strictures <ul><li>Causes: </li></ul><ul><li>Benign (I) </li></ul><ul><li>>Post-surgical (cholecystectomy, liver r...
Biliary Strictures <ul><li>Causes: </li></ul><ul><li>Benign (II) </li></ul><ul><li>>Vasculitis </li></ul><ul><li>>Blunt tr...
Biliary Strictures <ul><li>Causes: </li></ul><ul><li>Malignant </li></ul><ul><li>>Pancreatic adenocarcinoma </li></ul><ul>...
Managing Biliary Strictures <ul><li>Investigation of Biliary Strictures : </li></ul><ul><li>Imaging Modalities </li></ul><...
 
Managing Biliary Strictures <ul><li>Investigation of Biliary Strictures : </li></ul><ul><li>Imaging Modalities </li></ul><...
Managing Biliary Strictures <ul><li>Investigation of Biliary Strictures : </li></ul><ul><li>Imaging Modalities </li></ul><...
Managing Biliary Strictures <ul><li>Investigation of Biliary Strictures : </li></ul><ul><li>Imaging Modalities </li></ul><...
 
 
mass mass EUS in malignancy EUS diagnosis and Whipple resection of 15mm pancreatic cancer missed by CT
 
 
 
 
 
 
 
 
Managing Biliary Strictures <ul><li>Investigation of Biliary Strictures : </li></ul><ul><li>Imaging Modalities </li></ul><...
 
Managing Biliary Strictures <ul><li>Investigation of Biliary Strictures : </li></ul><ul><li>Imaging Modalities </li></ul><...
 
 
 
Managing Biliary Strictures <ul><li>Investigation of Biliary Strictures : </li></ul><ul><li>Imaging Modalities </li></ul><...
 
 
 
Managing Biliary Strictures <ul><li>Investigation of Biliary Strictures : </li></ul><ul><li>Imaging Modalities </li></ul><...
Managing Biliary Strictures <ul><li>Investigation of Biliary Strictures : </li></ul><ul><li>Imaging Modalities </li></ul><...
 
 
Managing Biliary Strictures <ul><li>Investigation of Biliary Strictures : </li></ul><ul><li>Imaging Modalities </li></ul><...
Managing Biliary Strictures <ul><li>Investigation of Biliary Strictures : </li></ul><ul><li>Imaging Modalities </li></ul><...
 
Managing Biliary Strictures <ul><li>Investigation of Biliary Strictures : </li></ul><ul><li>Imaging Modalities </li></ul><...
 
Managing Biliary Strictures <ul><li>Investigation of Biliary Strictures : </li></ul><ul><li>Imaging Modalities </li></ul><...
 
Confocal Microscopy
 
 
 
CYTOLOGY
CYTOLOGY BRUSH
Brush cytology: yield about 30%
HOWELL NEEDLE, BIOPSY FORCEPS
Needle core/biopsy: yield about 50-60%
 
F.I.S.H.
F.I.S.H. Fluorescent In Situ Hybridization
 
 
BANANA CHROMOSOMES
 
 
 
PROTEOMICS
Markers in Pancreatic Cancer <ul><li>Mic-1 (macrophage inhibitory cytokine 1) </li></ul><ul><li>90% of patients with pancr...
Positive MIC-1 Staining
Diagnosis of Malignancy <ul><li>Clinical course (“give cancer a chance”..) </li></ul><ul><li>CT- or EUS-guided fine needle...
Diagnosis of Malignancy in Biliary Strictures <ul><li>Clinical course (“give cancer a chance”..) </li></ul><ul><li>CT- or ...
Diagnosis of Malignancy in Biliary Strictures <ul><li>Clinical course (“give cancer a chance”..) </li></ul><ul><li>CT- or ...
 
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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

  1. 1. John Baillie, MB ChB, FRCP, FACG, FASGE Wake Forest University Health Sciences Winston-Salem, North Carolina
  2. 7. VICTORIA INFIRMARY, GLASGOW, SCOTLAND
  3. 9. MINNEAPOLIS, MINNESOTA, USA
  4. 11. MIDDLESEX HOSPITAL, LONDON TOWER BRIDGE, LONDON
  5. 13. DUKE UNIVERSITY MEDICAL CENTER
  6. 15. WAKE FOREST UNIVERSITY HEALTH SCIENCES, WINSTON-SALEM, NORTH CAROLINA, USA
  7. 17. ERCP
  8. 18. Managing Biliary Strictures <ul><li>Presentation </li></ul><ul><li>Asymptomatic - often an incidental finding </li></ul>
  9. 19. Managing Biliary Strictures <ul><li>Presentation </li></ul><ul><li>Asymptomatic - often an incidental finding </li></ul><ul><li>Symptomatic - pain, fever, jaundice, elevated liver enzymes </li></ul>
  10. 20. Managing Biliary Strictures <ul><li>Presentation </li></ul><ul><li>Asymptomatic - often an incidental finding </li></ul><ul><li>Symptomatic - pain, fever, jaundice, elevated liver enzymes </li></ul><ul><li>The diagnosis is often suggested by the clinical situation. </li></ul>
  11. 21. 33 year old man with longstanding ulcerative colitis
  12. 22. Primary Sclerosing Cholangitis
  13. 23. 40 yr old woman with fever and malaise after lap cholecystectomy
  14. 24. Ischemic injury to R main hepatic duct from misplaced clip
  15. 25. Ischemic injury to R main hepatic duct from misplaced clip
  16. 26. 75 year old man with progressive painless jaundice and itching
  17. 27. Mass at the biliary confluence: cholangiocarcinoma (Klatskin tumor)
  18. 28. CLASSIFICATION OF KLATSKIN TUMORS
  19. 29. Managing Biliary Strictures <ul><li>Klatskin tumor – a disease of the elderly </li></ul>
  20. 30. What is “elderly”?
  21. 31. Biliary Strictures <ul><li>Causes: </li></ul><ul><li>Benign (I) </li></ul><ul><li>>Post-surgical (cholecystectomy, liver resection, transplantation) </li></ul><ul><li>>Chronic pancreatitis </li></ul><ul><li>>Primary sclerosing cholangitis </li></ul><ul><li>> HIV cholangiopathy </li></ul><ul><li>>Mirizzi syndrome </li></ul><ul><li>>Irradiation </li></ul>
  22. 32. Biliary Strictures <ul><li>Causes: </li></ul><ul><li>Benign (II) </li></ul><ul><li>>Vasculitis </li></ul><ul><li>>Blunt trauma </li></ul><ul><li>>Tuberculosis </li></ul><ul><li>>Intra-arterial chemotherapy (FUDR) </li></ul><ul><li>>Choledochal cysts </li></ul><ul><li>>Oriental (recurrent pyogenic) cholangitis </li></ul><ul><li>>Hepatic pseudotumor </li></ul>
  23. 33. Biliary Strictures <ul><li>Causes: </li></ul><ul><li>Malignant </li></ul><ul><li>>Pancreatic adenocarcinoma </li></ul><ul><li>>Mucinous cystadenocarcinoma </li></ul><ul><li>>Ampullary adenocarcinoma </li></ul><ul><li>>Gallbladder carcinoma </li></ul><ul><li>>Cholangiocarcinoma </li></ul><ul><li>>Hepatoma </li></ul><ul><li>>Lymphoma and metastatic malignancy </li></ul>
  24. 34. Managing Biliary Strictures <ul><li>Investigation of Biliary Strictures : </li></ul><ul><li>Imaging Modalities </li></ul><ul><li>> Transabdominal ultrasound (TUS) </li></ul>
  25. 36. Managing Biliary Strictures <ul><li>Investigation of Biliary Strictures : </li></ul><ul><li>Imaging Modalities </li></ul><ul><li>>Transabdominal ultrasound (TUS) </li></ul><ul><li>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… </li></ul>
  26. 37. Managing Biliary Strictures <ul><li>Investigation of Biliary Strictures : </li></ul><ul><li>Imaging Modalities </li></ul><ul><li>>Transabdominal ultrasound (TUS) </li></ul><ul><li>> Endoscopic ultrasound (EUS) </li></ul>
  27. 38. Managing Biliary Strictures <ul><li>Investigation of Biliary Strictures : </li></ul><ul><li>Imaging Modalities </li></ul><ul><li>>Endoscopic ultrasound (EUS) </li></ul><ul><li>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. </li></ul>
  28. 41. mass mass EUS in malignancy EUS diagnosis and Whipple resection of 15mm pancreatic cancer missed by CT
  29. 50. Managing Biliary Strictures <ul><li>Investigation of Biliary Strictures : </li></ul><ul><li>Imaging Modalities </li></ul><ul><li>>Transabdominal ultrasound (TUS) </li></ul><ul><li>>Endoscopic ultrasound (EUS) </li></ul><ul><li>> Computed tomography (CT) scan </li></ul>
  30. 52. Managing Biliary Strictures <ul><li>Investigation of Biliary Strictures : </li></ul><ul><li>Imaging Modalities </li></ul><ul><li>>Computed tomography (CT) scan: </li></ul><ul><li>Good for masses, vascular involvement in tumors, biliary and pancreatic ductal dilatation, lymphadenopathy, fluid collections, stones >5mm in diameter, metastases (e.g local, liver). </li></ul>
  31. 56. Managing Biliary Strictures <ul><li>Investigation of Biliary Strictures : </li></ul><ul><li>Imaging Modalities </li></ul><ul><li>>Transabdominal ultrasound (TUS) </li></ul><ul><li>>Endoscopic ultrasound (EUS) </li></ul><ul><li>>Computed tomography (CT) scan </li></ul><ul><li>> Magnetic resonance cholangiopancreatography (MRCP) </li></ul>
  32. 60. Managing Biliary Strictures <ul><li>Investigation of Biliary Strictures : </li></ul><ul><li>Imaging Modalities </li></ul><ul><li>>Magnetic resonance cholangiopancreatography (MRCP) </li></ul><ul><li>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 </li></ul>
  33. 61. Managing Biliary Strictures <ul><li>Investigation of Biliary Strictures : </li></ul><ul><li>Imaging Modalities </li></ul><ul><li>>Transabdominal ultrasound (TUS) </li></ul><ul><li>>Endoscopic ultrasound (EUS) </li></ul><ul><li>>Computed tomography (CT) scan </li></ul><ul><li>>Magnetic resonance cholangiopancreatography (MRCP) </li></ul><ul><li>> Percutaneous transhepatic cholangiography (PTC) </li></ul>
  34. 64. Managing Biliary Strictures <ul><li>Investigation of Biliary Strictures : </li></ul><ul><li>Imaging Modalities </li></ul><ul><li>>Percutaneous transhepatic cholangiography (PTC) </li></ul><ul><li>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. </li></ul>
  35. 65. Managing Biliary Strictures <ul><li>Investigation of Biliary Strictures : </li></ul><ul><li>Imaging Modalities </li></ul><ul><li>>Transabdominal ultrasound (TUS) </li></ul><ul><li>>Endoscopic ultrasound (EUS) </li></ul><ul><li>>Computed tomography (CT) scan </li></ul><ul><li>>Magnetic resonance cholangiopancreatography (MRCP) </li></ul><ul><li>>Percutaneous transhepatic cholangiography (PTC) </li></ul><ul><li>> Endoscopic retrograde cholangiopancreatography (ERCP) </li></ul>
  36. 67. Managing Biliary Strictures <ul><li>Investigation of Biliary Strictures : </li></ul><ul><li>Imaging Modalities </li></ul><ul><li>>Transabdominal ultrasound (TUS) </li></ul><ul><li>>Endoscopic ultrasound (EUS) </li></ul><ul><li>>Computed tomography (CT) scan </li></ul><ul><li>>Magnetic resonance cholangiopancreatography (MRCP) </li></ul><ul><li>>Percutaneous transhepatic cholangiography (PTC) </li></ul><ul><li>>Endoscopic retrograde cholangiopancreatography (ERCP) </li></ul><ul><li>>Intraductal ultrasound </li></ul>
  37. 69. Managing Biliary Strictures <ul><li>Investigation of Biliary Strictures : </li></ul><ul><li>Imaging Modalities </li></ul><ul><li>> Intraductal ultrasound (IDUS) / choledochoscopy </li></ul><ul><li>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. </li></ul>
  38. 71. Confocal Microscopy
  39. 75. CYTOLOGY
  40. 76. CYTOLOGY BRUSH
  41. 77. Brush cytology: yield about 30%
  42. 78. HOWELL NEEDLE, BIOPSY FORCEPS
  43. 79. Needle core/biopsy: yield about 50-60%
  44. 81. F.I.S.H.
  45. 82. F.I.S.H. Fluorescent In Situ Hybridization
  46. 85. BANANA CHROMOSOMES
  47. 89. PROTEOMICS
  48. 90. Markers in Pancreatic Cancer <ul><li>Mic-1 (macrophage inhibitory cytokine 1) </li></ul><ul><li>90% of patients with pancreatic CA had Mic-1 levels > 2 SD above the mean for healthy controls. </li></ul><ul><li>Mic-1 and CA19-9 showed similar sensitivity for distinguishing CP from CA </li></ul>Courtesy of Dr Michelle Anderson, MD
  49. 91. Positive MIC-1 Staining
  50. 92. Diagnosis of Malignancy <ul><li>Clinical course (“give cancer a chance”..) </li></ul><ul><li>CT- or EUS-guided fine needle aspiration biopsy </li></ul><ul><li>Endoscopic (or radiologic) brush cytology </li></ul><ul><li>Endoscopic (or radiologic) needle core (Howell needle) or direct biopsy </li></ul><ul><li>“ Salvage” cytology </li></ul><ul><li>Flow cytometry </li></ul><ul><li>Fluorescent in-situ hybridization (FISH) </li></ul><ul><li>Proteomics (cell surface antigens) </li></ul><ul><li>Serologic markers: CEA, CA19-9, etc </li></ul><ul><li>PET/CT scanning </li></ul>
  51. 93. Diagnosis of Malignancy in Biliary Strictures <ul><li>Clinical course (“give cancer a chance”..) </li></ul><ul><li>CT- or EUS-guided fine needle aspiration biopsy </li></ul><ul><li>Endoscopic (or radiologic) brush cytology </li></ul><ul><li>Endoscopic (or radiologic) needle core (Howell needle) or direct biopsy </li></ul><ul><li>“ Salvage” cytology </li></ul><ul><li>Flow cytometry ∞ </li></ul><ul><li>Fluorescent in-situ hybridization (FISH) ∞ </li></ul><ul><li>Proteomics (cell surface antigens) ∞ </li></ul><ul><li>Serologic markers: CEA, CA19-9, etc </li></ul><ul><li>PET/CT scanning </li></ul><ul><li>∞ = expensive </li></ul>
  52. 94. Diagnosis of Malignancy in Biliary Strictures <ul><li>Clinical course (“give cancer a chance”..) </li></ul><ul><li>CT- or EUS-guided fine needle aspiration biopsy </li></ul><ul><li>Endoscopic (or radiologic) brush cytology </li></ul><ul><li>Endoscopic (or radiologic) needle core (Howell needle) or direct biopsy </li></ul><ul><li>“ Salvage” cytology </li></ul><ul><li>Flow cytometry ∞ </li></ul><ul><li>Fluorescent in-situ hybridization (FISH) ∞ </li></ul><ul><li>Proteomics (cell surface antigens) ∞ </li></ul><ul><li>Serologic markers: CEA, CA19-9, etc </li></ul><ul><li>PET/CT scanning •• Confocal Microscopy </li></ul><ul><li>∞ = expensive </li></ul>

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