Endoscopic management of primary sclerosing cholangitis

Primary sclerosing cholangitis (PSC) is a progressive autoimmune hepatobiliary disease characterized by fibrotic strictures in the bile ducts, leading to chronic cholestasis and cirrhosis. Magnetic resonance cholangiopancreatography (MRCP) is a noninvasive method for evaluating the condition of the bile ducts, and has high sensitivity and specificity, making it the first-line diagnostic tool for PSC. However, the importance of endoscopic retrograde cholangiopancreatography (ERCP) remains unchanged. ERCP is particularly useful in differentiating PSC from cholangiocarcinoma. It allows for tissue sampling from strictures and offers superior spatial resolution to detect subtle changes in the bile ducts. Endoscopic ultrasonography (EUS) is a minimally invasive endoscopic modality with growing importance in the management of pancreato-biliary diseases. Although the role of EUS in PSC patients has not been established, future research in this area is warranted. ERCP is particularly important for patients who are not eligible for liver transplantation, as it allows bile drainage from the dominant or high-grade strictures through balloon dilation and stenting, alleviating symptoms and extending survival. Balloon dilation is currently considered superior to biliary stenting, due to its lower risk of bacterial cholangitis. However, refractory complications, such as bacterial cholangitis and pancreatitis, can still occur in some cases. Therefore, careful patient selection and involvement of highly skilled specialists are essential. In the diagnosis and treatment of PSC, it is crucial to perform endoscopic procedures tailored to its unique pathophysiology. Further research is needed to optimize treatment protocols and improve outcomes. This review presents the latest insights on these topics.