ASGE Annual GI Advanced Practice Provider Course (Virtual) (Day One) | March 2026-Radiology Studies Case 2-Biliary Stricture

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The document presents two teaching cases on evaluating biliary strictures and cholestatic liver test abnormalities, emphasizing the “gray zone” of indeterminate biliary strictures and the diagnosis/management of primary sclerosing cholangitis (PSC).

<strong>Case 1 (62-year-old woman):</strong> She presents with jaundice and unintentional weight loss. CT shows a distal common bile duct (CBD) stricture with upstream biliary dilation and an enlarged, calcified pancreatic head, raising concern for chronic pancreatitis versus pancreatic cancer causing biliary obstruction. Labs show a cholestatic pattern (elevated alkaline phosphatase and bilirubin) with mild transaminase elevation. The workup highlights selection among ultrasound, MRCP, ERCP, serologies, autoimmune testing, tumor markers, and alcohol biomarkers. Additional testing reveals negative viral serologies, negative IgG4 (arguing against IgG4-related disease), mildly elevated CA 19-9, and low PEth. ERCP brushings show atypical cells but no overt malignancy. The key teaching point is that “negative” or atypical brush cytology does not exclude cancer; brush cytology sensitivity is limited. Strategies to improve diagnosis include intraductal biopsies, FISH (which can double detection when combined with cytology), cholangioscopy with targeted biopsy, and EUS-guided FNA/FNB. If suspicion remains high despite nondiagnostic pathology, repeat evaluation (often every 3–6 months) and referral to a multidisciplinary hepatobiliary team are recommended.

<strong>Case 2 (25-year-old man):</strong> Routine labs show mild cholestatic abnormalities and pruritus, with a history of ulcerative colitis. MRCP images (not detailed in text) support PSC, an autoimmune, progressive inflammatory/fibrosing bile duct disease leading to obstruction, recurrent cholangitis, pruritus, cirrhosis/portal hypertension, and increased malignancy risk (cholangiocarcinoma, gallbladder cancer, and colon cancer). Discussion focuses on appropriate further bloodwork, imaging, possible ERCP, tumor markers, colonoscopy, gallbladder evaluation, longitudinal hepatology care, symptom management, cancer surveillance, and transplantation considerations.

Asset Subtitle

Katelyn Cookson, PA-C, and John A. Martin, MD, FASGE

Keywords

indeterminate biliary stricture

cholestatic liver enzyme abnormalities

ERCP brush cytology sensitivity

FISH for cholangiocarcinoma detection

cholangioscopy targeted biopsy

EUS-guided FNA/FNB

distal common bile duct (CBD) stricture

primary sclerosing cholangitis (PSC)

PSC and ulcerative colitis association

cholangiocarcinoma surveillance and management