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Evolving techniques to optimize ERCP-based sampling and evaluation of malignant biliary strictures.
Chinmay Guralwar1, Manik Aggarwal1, Jyotroop Kaur1,2
1Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Rochester, MN 55905, United States.
Gastroenterology Report
|July 1, 2026
Summary
Endoscopic retrograde cholangiopancreatography (ERCP) tissue acquisition for malignant biliary strictures has low sensitivity. Emerging techniques like peroral cholangioscopy (POC) and molecular markers improve cancer detection, guiding better management.
Area of Science:
- Gastroenterology
- Oncology
- Diagnostic Pathology
Background:
- Endoscopic retrograde cholangiopancreatography (ERCP)-based tissue acquisition is crucial for diagnosing malignant biliary strictures.
- Conventional methods (biliary brush cytology, forceps biopsy) have high specificity but limited sensitivity, often resulting in non-definitive diagnoses.
- Improving diagnostic accuracy for biliary tract cancers remains a significant clinical challenge.
Purpose of the Study:
- To review established and novel ERCP-guided tissue acquisition techniques for malignant biliary strictures.
- To evaluate the clinical performance, strengths, and limitations of these diagnostic modalities.
- To emphasize the evolving role of multimodal sampling in enhancing diagnostic accuracy.
Main Methods:
- Review of current literature on ERCP-based tissue acquisition techniques.
- Analysis of adjunctive modalities including peroral cholangioscopy (POC)-guided biopsies.
- Evaluation of molecular techniques such as fluorescence in situ hybridization (FISH), next-generation sequencing, and methylated DNA markers.
- Consideration of artificial intelligence (AI)-augmented visualization and liquid biopsy.
Main Results:
- Peroral cholangioscopy (POC)-guided biopsies offer direct visualization and targeted sampling, improving yield after non-diagnostic procedures.
- Molecular techniques like FISH, next-generation sequencing, and methylated DNA markers show promise for enhanced sensitivity and identifying actionable alterations.
- Multimodal sampling, combining at least two techniques, is recommended by current guidelines to optimize diagnostic accuracy.
Conclusions:
- Established ERCP techniques have limitations in sensitivity for diagnosing malignant biliary strictures.
- Emerging adjunctive techniques, including POC, molecular markers, and AI, significantly enhance diagnostic sensitivity and accuracy.
- A multimodal approach to ERCP-based sampling is essential for improving the diagnosis and management of malignant biliary strictures.
