Diagnosing hilar cholangiocarcinoma: ERCP with cholangioscopy

Cholangiocarcinoma of the hepatic hilum represents a challenge in its diagnosis, in the palliation of the frequently associated jaundice, and in its treatment. Noninvasive imaging tests can offer a fairly accurate diagnostic approximation, but very often a histopathological diagnosis is necessary to exclude the so-called Klatskin-mimicking lesions, which can reach up to 20% in surgical series. ERCP is the most commonly used endoscopic procedure, both for tissue acquisition and for palliation of jaundice. Although probably underused, intraductal ultrasonography performed during ERCP can provide valuable information for the diagnosis of hilar cholangiocarcinoma. During ERCP, brush cytology and biopsy are performed to acquire tissue for histopathological confirmation of cholangiocarcinoma. The sensitivity of both methods alone is less than 50%. When biopsies are taken through a cholangioscope, the sensitivity is significantly increased. In this editorial we discuss a study by Alonso-Lárraga et al. published in the Spanish Journal of Gastroenterology. The highest sensitivity (77.4%) was obtained when 4 to 6 biopsies were taken with the SpyGlass cholangioscope. Direct visualization of lesions and the higher diagnostic yield of biopsies make ERCP with cholangioscopy the standard approach for patients with suspected perihilar cholangiocarcinoma.