VideoGIE
A case of unusual indeterminate biliary stricture
Figure 1. A, MRCP showing dilated intrahepatic duct with stricture at hilar bifurcation (arrow). B, Biliary stricture with extensive ulceration. C, Narrow-band imaging of the biliary stricture.
Biliary stricture is a rare sequela of biliary tuberculosis (TB) infection. Early recognition with prompt treatment can result in complete resolution. A 56-year-old man was diagnosed with biliary TB after analysis of bile from ERCP showed positive results for TB. Bile duct brushings were inconclusive. Despite completing 7 months of anti-TB treatment, the patient’s liver function test results were still abnormal. MRCP showed dilated intrahepatic ducts with a stricture at the hilar bifurcation (Fig. 1A), which raised a concern about malignant biliary stricture. Therefore, repeated ERCP with cholangioscopy was performed. The cholangiogram showed a long stricture at the bifurcation of the common hepatic duct and dilation of the intrahepatic duct. Balloon dilatation to 8 mm was performed for insertion of a cholangioscope. A CHF-B260 cholangioscope (Olympus Medical Systems, Tokyo, Japan), inserted over a guidewire, was passed to the distal margin of the stricture. The strictured area showed extensive ulceration (Fig. 1B). Narrow-band imaging did not show neovascularization or nodularity to suggest a malignant This video can be viewed directly from the GIE website or by using the QR code and your mobile device. Download a free QR code scanner by searching “QR Scanner” in your mobile device’s app store.
168 GASTROINTESTINAL ENDOSCOPY Volume 82, No. 1 : 2015
stricture (Fig. 1C). Bile fluid was aspirated for TB analysis. The SpyBite biopsy forcep (Boston Scientific, Natick, Mass) was used to take multiple biopsy specimens from ulcerated areas. A 10F 12-cm plastic biliary stent was placed with the proximal tip above the biliary stricture (Video 1, available online at www. giejournal.org). Histopathologic examination showed a granulomatous focus with giant cells. The patient’s diagnosis was biliary stricture secondary to biliary TB. He was treated with another course of anti-TB treatment and is making a good recovery. DISCLOSURE All authors disclosed no financial relationships relevant to this publication. Yung Ka Chin, MB, ChB, MRCP, Damien Meng Yew Tan, MBBS, MRCP, FAMS, Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore, Kiat Hon Lim, MBBS, MRCPath, FRCPA, Department of Pathology, Singapore General Hospital, Singapore, Christopher Jen Lock Khor, MBBS, FRCP, FAMS, FASGE, Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore http://dx.doi.org/10.1016/j.gie.2015.01.009
www.giejournal.org
A case of unusual indeterminate biliary stricture
Figure 1. A, MRCP showing dilated intrahepatic duct with stricture at hilar bifurcation (arrow). B, Biliary stricture with extensive ulceration. C, Narrow-band imaging of the biliary stricture.
Biliary stricture is a rare sequela of biliary tuberculosis (TB) infection. Early recognition with prompt treatment can result in complete resolution. A 56-year-old man was diagnosed with biliary TB after analysis of bile from ERCP showed positive results for TB. Bile duct brushings were inconclusive. Despite completing 7 months of anti-TB treatment, the patient’s liver function test results were still abnormal. MRCP showed dilated intrahepatic ducts with a stricture at the hilar bifurcation (Fig. 1A), which raised a concern about malignant biliary stricture. Therefore, repeated ERCP with cholangioscopy was performed. The cholangiogram showed a long stricture at the bifurcation of the common hepatic duct and dilation of the intrahepatic duct. Balloon dilatation to 8 mm was performed for insertion of a cholangioscope. A CHF-B260 cholangioscope (Olympus Medical Systems, Tokyo, Japan), inserted over a guidewire, was passed to the distal margin of the stricture. The strictured area showed extensive ulceration (Fig. 1B). Narrow-band imaging did not show neovascularization or nodularity to suggest a malignant This video can be viewed directly from the GIE website or by using the QR code and your mobile device. Download a free QR code scanner by searching “QR Scanner” in your mobile device’s app store.
168 GASTROINTESTINAL ENDOSCOPY Volume 82, No. 1 : 2015
stricture (Fig. 1C). Bile fluid was aspirated for TB analysis. The SpyBite biopsy forcep (Boston Scientific, Natick, Mass) was used to take multiple biopsy specimens from ulcerated areas. A 10F 12-cm plastic biliary stent was placed with the proximal tip above the biliary stricture (Video 1, available online at www. giejournal.org). Histopathologic examination showed a granulomatous focus with giant cells. The patient’s diagnosis was biliary stricture secondary to biliary TB. He was treated with another course of anti-TB treatment and is making a good recovery. DISCLOSURE All authors disclosed no financial relationships relevant to this publication. Yung Ka Chin, MB, ChB, MRCP, Damien Meng Yew Tan, MBBS, MRCP, FAMS, Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore, Kiat Hon Lim, MBBS, MRCPath, FRCPA, Department of Pathology, Singapore General Hospital, Singapore, Christopher Jen Lock Khor, MBBS, FRCP, FAMS, FASGE, Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore http://dx.doi.org/10.1016/j.gie.2015.01.009
www.giejournal.org
