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Indeterminate Strictures
of Biliary System – Role
of Advanced Imaging Viren Joshi MD, AGAF,FACG
Clinical Professor Louisiana State University
Professor University of Queensland,Australia
Australia
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Indeterminate Biliary
Strictures : Inflammatory – Autoimmune , PSC , Chronic
Pancreatitis
Trauma / Ischemia
Chemoembolization
Transplant / Biliary surgery
Infections
Choledochal cyst
Malignant - Cholangiocarcinoma
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Diagnostic Challenge
Traditionally : EUS ( IDUS ) , ERCP, Biomarkers (
Poor sensitivity )
20% of biliary strictures remain indeterminate and
need surveillance or surgery
No standard prescription how to evaluate – use
tailored approach based on available technology
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Pathway Diagnosis : History
Radiologic Imaging
Endoscopy - Brushing , FISH ( polysomy )
Biomarkers - CA 19-9
Advanced Imaging :Single operator
Cholangioscopy, Endomicroscopy
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PSC strictures / Cholangio
CA :
Increase yield with more samples
EUS staging and FNA
FISH also has not increased sensitivity
Spyglass / Spybite forceps ( limited data, small numbers, cholangitis )
Recently Endomicroscopy to – improve yield and target biopsies
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Case: Indeterminate 73 Y/O with mild elevated liver tests
Ca-19-9 normal, IgG4 Normal
No Alarm symptoms
Enlarged Lymph nodes Hilum
Enlarged HOP
MRCP
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Hilar Lesion:Single operator
cholangioscope
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Probe Based
Endomicroscopy :pCLE
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IgG4 Negative Autoimmune
Cholangitis :
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Proposed diagnostic approach to biliary strictures.
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Proximal :
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Distal :
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Intraductal Imaging of CBD: Challenging
SOC ( Spyglass )
Endomicroscopy – CLE
Cholangioflex with delivered via swing tip canula
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EMR Case Next Slides
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Indeterminate Strictures : pCLE Operating
Characteristics
kappa statistic, stent changes
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Miami Criteria: 2009
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Malignant:
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Paris Criteria :
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Paris Criteria :2015
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Inflammatory :
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Validation with Paris
Criteria:
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Kappa Statistic
.56 ( moderate )
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pCLE Vs Tissue Sampling
in Dominant PSC Strictures :
Multivariate Regression analysis
A U.S. Multi-Center, Prospective Registry Study
Utilizing Probe-Based Confocal Laser
Endomicroscopy (PCLE) to Distinguish Benign
From Malignant Dominant Biliary Strictures in
Patients With Primary Sclerosing Cholangitis
Raj J. Shah, Virendra Joshi, Michel Kahaleh, Adam Slivka, Paul R.
Tarnasky, Divyesh V. Sejpal, Amrita Sethi, Philip D. Tatman,
Timothy M. Tynan, Sachin B. Wani, Brian C. Brauer, Reem Z.
Sharaiha, Prashant Kedia, Cris Molina
GIE ( DDW ) May 2017, Volume 85, Issue 5, Supplement, Pages AB611–AB612
1. pCLE superior to tissue sampling
2. Paris criteria may have some limitations in these strictures due to
Extensive scarring to detect neoplasia
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Reflection / transmission - of Near infrared LASER light
Creates an Image pattern described as “hyper or hypo-refective “
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Why OCT in Bile duct ? Can we better
target biopsies ?
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NO Baloon
Biliary Probe
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Normal
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Duodenum Normal CBD
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Normal Bile DuctEpithelium/Single Layer
1mm
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Normal Bile DuctEpithelium/Single Layer
1mm
Different image
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Thickening of
wall +
inflammation
Eroded Surface Epithelium
Inflamed bile duct wall
PSC/Inflammatory Disease
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Inflammation around
peribiliary glands
PSC/Inflammatory Disease
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CCA Image 1
Cholangiocarcinoma
Normal SurfaceEpithelium
Infiltrating Malignant Glands
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CCA Image 1
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CCA Image 2
Bile Duct
Cholangiocarcinoma
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A Pilot study of Safety and Efficacy of directed cannulation
with a Low Profile catheter ( LP ) and imaging characteristics
of bile duct wall using Optical Coherance tomography ( OCT )
for indeterminate biliary strictures –
Initial report on in-vivo evaluation during ERCP :
: Virendra Joshi1, 6, Sandeep N. Patel5, Hendrikus
Vanderveldt4, Irma oliva
3, Isaac Raijman5, Cris Molina1, David L. Carr-Locke2
Conclusion:
1. VLE of the bile duct using the Nvision platform and a
novel LP catheter is feasible and safe
2. A two-layered structure in normal and inflammatory
biliary strictures was seen consistantly, malignant
strictures
demonstrated complete loss of layering
3. VLE of pancreatobiliary system has potential to define
abnormalities, target sampling and therapyDDW 2017 , Chicago
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Case Review : Pt. presents with normal appearing ampulla;
cannulated the CBD with a standard sphincterotome and .025 wire, Ominpaque injected and the Cholangiogram showed a mid to distal CBD stricture approximately 2 cm in length. A sphincterotomy was then done. The wire was left in and then aVLE Low Profile probe was placed along side the wire and a full scan was completed without any difficulty. VLE Tags were laid at frame 560 beginning of the stricture confirmed by fluoro and 1059 end of stricture confirmed by flouro. Spyglass was then used to visualize the area of concern and bx’s were taken. Brushings were also taken of the suspected area.
Pathology results: Atypical cells, adenocarcinoma
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Cholangiogram
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Fluoro Confirmation of the
location of the LP PRobe
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SpyGlass Image of strictured
area
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SpyGlass Image and Spybite
Image
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Beginning of stricture
POSSIBLE INVASIVE
MALIGNANT
GLANDS, beginning of
scalped appearance
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Middle of stricture Frame
764
• Loss of layering
• Eroded epithelium
• “Scalloping” look
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Middle of stricture Frame
764
• Loss of layering
• Eroded epithelium
• “Scalloping” look
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Histology image from
Spybite
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Conclusion: CLE/VLE impact will only increase as enhanced
user image interpretation capability and newly
available technical improvements further the ability
to identify and target advanced disease missed by
other techniques.
Artificial Intelligence and computer aided
interpretation should be available in near future
….. And MILES to go before I sleep…. ( Sir Robert
Frost )