Endoscopic management of biliary stricture in primary sclerosing cholangitis

Primary sclerosing cholangitis (PSC) is a progressive fibroinflammatory disease characterized by multifocal biliary strictures, recurrent cholangitis, and a markedly increased lifetime risk of cholangiocarcinoma (CCA). Endoscopic retrograde cholangiopancreatography (ERCP) remains central to the diagnosis of CCA and management of PSC-related complications. This review synthesizes current evidence guiding the use of ERCP in patients with PSC, highlighting the importance of careful patient selection to mitigate adverse events. We review traditional ERCP techniques for the evaluation of dominant strictures, such as brush cytology, fluorescence in situ hybridization, and biopsies, which exhibit limited sensitivity for detecting CCA in PSC. We also review the role of advanced endoscopic approaches, including cholangioscopy, endoscopic ultrasound, and confocal endomicroscopy, alongside novel molecular diagnostics (next-generation sequencing and DNA methylation markers), metabolomics, bile microbiome, and radiomics, which show promise for risk stratification and CCA detection in PSC. Therapeutically, we review evidence supporting the use of balloon dilation as first-line therapy for the management of PSC strictures and discuss settings where plastic stents might be beneficial. Furthermore, we review the endoscopic management of other PSC complications, such as cholangitis, stones, acute cholecystitis, and posttransplant strictures. Finally, we provide best-practice recommendations to minimize the risk of complications, including the use of periprocedural antibiotic prophylaxis, technique modifications, and individualized sphincterotomy decisions. As innovative diagnostic and therapeutic strategies for PSC continue to evolve, rigorous multicenter, prospective studies are needed to assess the efficacy, safety, and cost-effectiveness of these strategies before widespread adoption.