Endoscopic assessment of primary sclerosing cholangitis

Primary sclerosing cholangitis (PSC) is a rare chronic liver disease of unknown etiology for which the only known curative treatment is liver transplantation. The disease is defined by progressive inflammation and fibrosis of the bile ducts, causing biliary strictures and cholestasis. Common complications of the disease are the presence of biliary lithiasis requiring stone extraction, and development of dominant bile duct strictures requiring balloon dilatation and stent placement through endoscopic retrograde cholangiopancreatography. The increased development of cholangiocarcinoma is a dreaded complication in PSC, as it is often detected in an advanced stage and is associated with a poor prognosis. Several endoscopic techniques, including endoscopic ultrasound, confocal laser endomicroscopy and peroral cholangioscopy are applied in the management of PSC and detection of cholangiocarcinoma. Tissue sampling through different types of biopsies and biliary brush combined with fluorescence in situ hybridization are used to differentiate benign dominant strictures from biliary neoplasia. Nonetheless early detection of cholangiocarcinoma in PSC remains a clinical challenge requiring a specialized diagnostic workup. The aim of this review is to discuss the role of diagnostic and therapeutic endoscopy in management of PSC, providing an overview of current literature.