Prospective study of biliary strictures to determine the predictors of malignancy

Vincent G. Bain, Neena Susan Abraham, Gian S. Jhangri, Tim W. Alexander, Ron C. Henning, Michael E. Hoskinson, Conor G. Maguire, Eoin A G Lalor, Daniel C. Sadowski

Research output: Contribution to journalArticle

42 Citations (Scopus)

Abstract

BACKGROUND: There have been few prospective studies regarding the investigation of biliary strictures, principally because of rapid technological change. The present study was designed to determine the sensitivity of various imaging studies for the detection of biliary strictures. Serum biochemistry and imaging studies were evaluated for their role in distinguishing benign from malignant strictures. METHODS: Thirty-one patients with suspected noncalculus biliary obstruction were enrolled consecutively in the study. A complete biochemical profile, ultrasound, Disida scan and cholangiogram (endoscopic retrograde cholangiopancreatography ERCP] or percutaneous cholangiogram) were obtained at study entry. Stricture etiology was determined based on cytology, biopsy and/or clinical follow-up at one year. RESULTS: Twenty-nine of 31 patients had biliary strictures, of which 15 were malignant. The mean age of the malignant cohort was 73.9 years versus 53.9 years in the benign cohort (P < 0.001). Statistically significant differences between the malignant and benign groups, respectively, were as follows: alanine transaminase 235.2 versus 66.9 U/L (P = 0.004), aspartate transaminase 189.8 versus 84.5 U/L (P = 0.011), alkaline phosphatase 840.2 versus 361.1 U/L (P = 0.002), bilirubin 317.8 versus 22.1-μmol/L (P < 0.001) and bile acids 242.5 versus 73.2 μmol/L (P = 0.001). Threshold analysis using receiver operative characteristic (ROC) curves demonstrated that a bilirubin level of 75 μmol/L was most predictive of malignant strictures. Intrahepatic duct dilation was present in 93% of malignant strictures versus 36% of benign strictures (P = 0.002). Common hepatic duct dilation was less discriminatory (malignant 13.5 versus benign 9.6 mm; P = 0.11). Ultrasound was highly sensitive (93%) in the detection of the primary tumour in the bile duct or pancreas, or in the visualization of nodal or liver metastases. In benign disease, ultrasound failed to detect evidence of intrahepatic or extrahepatic biliary dilation in most cases. Disida scans were not able to distinguish between malignant or benign strictures and could not accurately localize the level of obstruction. The sensitivity of Disida scan for the diagnosis of obstruction was 50%. Cholangiographic characterization of strictures revealed an equal distribution of smooth (eight of 13) and irregular (five of 13) strictures in the malignant group. Ten of 13 benign strictures were characterized as smooth. Malignant strictures were significantly longer than benign ones -30.3 versus 9.2 mm (P = 0.001). Threshold analysis using ROC curves showed that strictures greater than or equal to 14 mm were predictive of malignancy (sensitivity 78%, specificity 75%, log odds ratio 11.23). CONCLUSIONS: A serum bilirubin level of 75 μmol/L or higher, or a stricture length of greater than 14 mm was highly predictive of malignancy in patients with a biliary stricture. Ultrasound was useful in predicting malignant strictures by detecting either intrahepatic duct dilation or by visualizing the tumour (primary or metastases). Strictures with a 'benign' cholangiographic appearance are frequently malignant. Disida scan did not add additional information. ERCP is necessary to diagnose benign strictures, which tend to be less extensive at presentation.

Original languageEnglish (US)
Pages (from-to)397-402
Number of pages6
JournalCanadian Journal of Gastroenterology
Volume14
Issue number5
StatePublished - May 2000
Externally publishedYes

Fingerprint

Pathologic Constriction
Prospective Studies
Neoplasms
Dilatation
Endoscopic Retrograde Cholangiopancreatography
Bilirubin
Neoplasm Metastasis
Common Hepatic Duct
Aspartate Aminotransferases
Bile Ducts
Bile Acids and Salts
Serum
Alanine Transaminase
Biochemistry
Alkaline Phosphatase
Cell Biology
Pancreas

Keywords

  • Bile duct obstruction
  • Biliary tract neoplasms
  • Cholangiopancreatography
  • Cholestasis
  • Endoscopic retrograde cholangiopancreatography
  • Jaundice
  • Pancreatic neoplasms
  • Prospective studies

ASJC Scopus subject areas

  • Gastroenterology

Cite this

Bain, V. G., Abraham, N. S., Jhangri, G. S., Alexander, T. W., Henning, R. C., Hoskinson, M. E., ... Sadowski, D. C. (2000). Prospective study of biliary strictures to determine the predictors of malignancy. Canadian Journal of Gastroenterology, 14(5), 397-402.

Prospective study of biliary strictures to determine the predictors of malignancy. / Bain, Vincent G.; Abraham, Neena Susan; Jhangri, Gian S.; Alexander, Tim W.; Henning, Ron C.; Hoskinson, Michael E.; Maguire, Conor G.; Lalor, Eoin A G; Sadowski, Daniel C.

In: Canadian Journal of Gastroenterology, Vol. 14, No. 5, 05.2000, p. 397-402.

Research output: Contribution to journalArticle

Bain, VG, Abraham, NS, Jhangri, GS, Alexander, TW, Henning, RC, Hoskinson, ME, Maguire, CG, Lalor, EAG & Sadowski, DC 2000, 'Prospective study of biliary strictures to determine the predictors of malignancy', Canadian Journal of Gastroenterology, vol. 14, no. 5, pp. 397-402.
Bain VG, Abraham NS, Jhangri GS, Alexander TW, Henning RC, Hoskinson ME et al. Prospective study of biliary strictures to determine the predictors of malignancy. Canadian Journal of Gastroenterology. 2000 May;14(5):397-402.
Bain, Vincent G. ; Abraham, Neena Susan ; Jhangri, Gian S. ; Alexander, Tim W. ; Henning, Ron C. ; Hoskinson, Michael E. ; Maguire, Conor G. ; Lalor, Eoin A G ; Sadowski, Daniel C. / Prospective study of biliary strictures to determine the predictors of malignancy. In: Canadian Journal of Gastroenterology. 2000 ; Vol. 14, No. 5. pp. 397-402.
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abstract = "BACKGROUND: There have been few prospective studies regarding the investigation of biliary strictures, principally because of rapid technological change. The present study was designed to determine the sensitivity of various imaging studies for the detection of biliary strictures. Serum biochemistry and imaging studies were evaluated for their role in distinguishing benign from malignant strictures. METHODS: Thirty-one patients with suspected noncalculus biliary obstruction were enrolled consecutively in the study. A complete biochemical profile, ultrasound, Disida scan and cholangiogram (endoscopic retrograde cholangiopancreatography ERCP] or percutaneous cholangiogram) were obtained at study entry. Stricture etiology was determined based on cytology, biopsy and/or clinical follow-up at one year. RESULTS: Twenty-nine of 31 patients had biliary strictures, of which 15 were malignant. The mean age of the malignant cohort was 73.9 years versus 53.9 years in the benign cohort (P < 0.001). Statistically significant differences between the malignant and benign groups, respectively, were as follows: alanine transaminase 235.2 versus 66.9 U/L (P = 0.004), aspartate transaminase 189.8 versus 84.5 U/L (P = 0.011), alkaline phosphatase 840.2 versus 361.1 U/L (P = 0.002), bilirubin 317.8 versus 22.1-μmol/L (P < 0.001) and bile acids 242.5 versus 73.2 μmol/L (P = 0.001). Threshold analysis using receiver operative characteristic (ROC) curves demonstrated that a bilirubin level of 75 μmol/L was most predictive of malignant strictures. Intrahepatic duct dilation was present in 93{\%} of malignant strictures versus 36{\%} of benign strictures (P = 0.002). Common hepatic duct dilation was less discriminatory (malignant 13.5 versus benign 9.6 mm; P = 0.11). Ultrasound was highly sensitive (93{\%}) in the detection of the primary tumour in the bile duct or pancreas, or in the visualization of nodal or liver metastases. In benign disease, ultrasound failed to detect evidence of intrahepatic or extrahepatic biliary dilation in most cases. Disida scans were not able to distinguish between malignant or benign strictures and could not accurately localize the level of obstruction. The sensitivity of Disida scan for the diagnosis of obstruction was 50{\%}. Cholangiographic characterization of strictures revealed an equal distribution of smooth (eight of 13) and irregular (five of 13) strictures in the malignant group. Ten of 13 benign strictures were characterized as smooth. Malignant strictures were significantly longer than benign ones -30.3 versus 9.2 mm (P = 0.001). Threshold analysis using ROC curves showed that strictures greater than or equal to 14 mm were predictive of malignancy (sensitivity 78{\%}, specificity 75{\%}, log odds ratio 11.23). CONCLUSIONS: A serum bilirubin level of 75 μmol/L or higher, or a stricture length of greater than 14 mm was highly predictive of malignancy in patients with a biliary stricture. Ultrasound was useful in predicting malignant strictures by detecting either intrahepatic duct dilation or by visualizing the tumour (primary or metastases). Strictures with a 'benign' cholangiographic appearance are frequently malignant. Disida scan did not add additional information. ERCP is necessary to diagnose benign strictures, which tend to be less extensive at presentation.",
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TY - JOUR

T1 - Prospective study of biliary strictures to determine the predictors of malignancy

AU - Bain, Vincent G.

AU - Abraham, Neena Susan

AU - Jhangri, Gian S.

AU - Alexander, Tim W.

AU - Henning, Ron C.

AU - Hoskinson, Michael E.

AU - Maguire, Conor G.

AU - Lalor, Eoin A G

AU - Sadowski, Daniel C.

PY - 2000/5

Y1 - 2000/5

N2 - BACKGROUND: There have been few prospective studies regarding the investigation of biliary strictures, principally because of rapid technological change. The present study was designed to determine the sensitivity of various imaging studies for the detection of biliary strictures. Serum biochemistry and imaging studies were evaluated for their role in distinguishing benign from malignant strictures. METHODS: Thirty-one patients with suspected noncalculus biliary obstruction were enrolled consecutively in the study. A complete biochemical profile, ultrasound, Disida scan and cholangiogram (endoscopic retrograde cholangiopancreatography ERCP] or percutaneous cholangiogram) were obtained at study entry. Stricture etiology was determined based on cytology, biopsy and/or clinical follow-up at one year. RESULTS: Twenty-nine of 31 patients had biliary strictures, of which 15 were malignant. The mean age of the malignant cohort was 73.9 years versus 53.9 years in the benign cohort (P < 0.001). Statistically significant differences between the malignant and benign groups, respectively, were as follows: alanine transaminase 235.2 versus 66.9 U/L (P = 0.004), aspartate transaminase 189.8 versus 84.5 U/L (P = 0.011), alkaline phosphatase 840.2 versus 361.1 U/L (P = 0.002), bilirubin 317.8 versus 22.1-μmol/L (P < 0.001) and bile acids 242.5 versus 73.2 μmol/L (P = 0.001). Threshold analysis using receiver operative characteristic (ROC) curves demonstrated that a bilirubin level of 75 μmol/L was most predictive of malignant strictures. Intrahepatic duct dilation was present in 93% of malignant strictures versus 36% of benign strictures (P = 0.002). Common hepatic duct dilation was less discriminatory (malignant 13.5 versus benign 9.6 mm; P = 0.11). Ultrasound was highly sensitive (93%) in the detection of the primary tumour in the bile duct or pancreas, or in the visualization of nodal or liver metastases. In benign disease, ultrasound failed to detect evidence of intrahepatic or extrahepatic biliary dilation in most cases. Disida scans were not able to distinguish between malignant or benign strictures and could not accurately localize the level of obstruction. The sensitivity of Disida scan for the diagnosis of obstruction was 50%. Cholangiographic characterization of strictures revealed an equal distribution of smooth (eight of 13) and irregular (five of 13) strictures in the malignant group. Ten of 13 benign strictures were characterized as smooth. Malignant strictures were significantly longer than benign ones -30.3 versus 9.2 mm (P = 0.001). Threshold analysis using ROC curves showed that strictures greater than or equal to 14 mm were predictive of malignancy (sensitivity 78%, specificity 75%, log odds ratio 11.23). CONCLUSIONS: A serum bilirubin level of 75 μmol/L or higher, or a stricture length of greater than 14 mm was highly predictive of malignancy in patients with a biliary stricture. Ultrasound was useful in predicting malignant strictures by detecting either intrahepatic duct dilation or by visualizing the tumour (primary or metastases). Strictures with a 'benign' cholangiographic appearance are frequently malignant. Disida scan did not add additional information. ERCP is necessary to diagnose benign strictures, which tend to be less extensive at presentation.

AB - BACKGROUND: There have been few prospective studies regarding the investigation of biliary strictures, principally because of rapid technological change. The present study was designed to determine the sensitivity of various imaging studies for the detection of biliary strictures. Serum biochemistry and imaging studies were evaluated for their role in distinguishing benign from malignant strictures. METHODS: Thirty-one patients with suspected noncalculus biliary obstruction were enrolled consecutively in the study. A complete biochemical profile, ultrasound, Disida scan and cholangiogram (endoscopic retrograde cholangiopancreatography ERCP] or percutaneous cholangiogram) were obtained at study entry. Stricture etiology was determined based on cytology, biopsy and/or clinical follow-up at one year. RESULTS: Twenty-nine of 31 patients had biliary strictures, of which 15 were malignant. The mean age of the malignant cohort was 73.9 years versus 53.9 years in the benign cohort (P < 0.001). Statistically significant differences between the malignant and benign groups, respectively, were as follows: alanine transaminase 235.2 versus 66.9 U/L (P = 0.004), aspartate transaminase 189.8 versus 84.5 U/L (P = 0.011), alkaline phosphatase 840.2 versus 361.1 U/L (P = 0.002), bilirubin 317.8 versus 22.1-μmol/L (P < 0.001) and bile acids 242.5 versus 73.2 μmol/L (P = 0.001). Threshold analysis using receiver operative characteristic (ROC) curves demonstrated that a bilirubin level of 75 μmol/L was most predictive of malignant strictures. Intrahepatic duct dilation was present in 93% of malignant strictures versus 36% of benign strictures (P = 0.002). Common hepatic duct dilation was less discriminatory (malignant 13.5 versus benign 9.6 mm; P = 0.11). Ultrasound was highly sensitive (93%) in the detection of the primary tumour in the bile duct or pancreas, or in the visualization of nodal or liver metastases. In benign disease, ultrasound failed to detect evidence of intrahepatic or extrahepatic biliary dilation in most cases. Disida scans were not able to distinguish between malignant or benign strictures and could not accurately localize the level of obstruction. The sensitivity of Disida scan for the diagnosis of obstruction was 50%. Cholangiographic characterization of strictures revealed an equal distribution of smooth (eight of 13) and irregular (five of 13) strictures in the malignant group. Ten of 13 benign strictures were characterized as smooth. Malignant strictures were significantly longer than benign ones -30.3 versus 9.2 mm (P = 0.001). Threshold analysis using ROC curves showed that strictures greater than or equal to 14 mm were predictive of malignancy (sensitivity 78%, specificity 75%, log odds ratio 11.23). CONCLUSIONS: A serum bilirubin level of 75 μmol/L or higher, or a stricture length of greater than 14 mm was highly predictive of malignancy in patients with a biliary stricture. Ultrasound was useful in predicting malignant strictures by detecting either intrahepatic duct dilation or by visualizing the tumour (primary or metastases). Strictures with a 'benign' cholangiographic appearance are frequently malignant. Disida scan did not add additional information. ERCP is necessary to diagnose benign strictures, which tend to be less extensive at presentation.

KW - Bile duct obstruction

KW - Biliary tract neoplasms

KW - Cholangiopancreatography

KW - Cholestasis

KW - Endoscopic retrograde cholangiopancreatography

KW - Jaundice

KW - Pancreatic neoplasms

KW - Prospective studies

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