Retrograde cholangiography of malignant biliary strictures: spectrum of appearances and pitfalls

To evaluate retrograde cholangiograms, explore the morphology of malignant biliary strictures, and determine if there are any features that may indicate a specific diagnosis.

The retrograde cholangiograms of 514 patients were reviewed. Cases with clinical follow-up and subsequent studies indicating malignant involvement of the biliary tree were identified. Fifty patients were found.

Carcinoma of the pancreatic head was the most common disease with 21 patients in this group. The morphology of the bile duct at the point of involvement was nonspecific comprising shouldered intrinsic appearing lesions as well as tapered in other cases. Pancreatic duct dilatation was a relatively specific finding occurring in 80% of this group. Other malignancies to involve the bile ducts included cholangiocarcinoma, metastases, ampullary carcinoma and gallbladder carcinoma. As with pancreatic carcinoma, the morphology of the lesion (e.g., shouldered versus tapered, length of stricture, severity of proximal dilatation) did not aid in the specific diagnosis of the pathology. Illustrative cases are presented where the morphology was unexpected for the eventual diagnosis (e.g., simulating intraluminal filling defects).

The cholangiographic appearance of a biliary stricture is usually not helpful in the specific diagnosis of the underlying etiology. Carcinoma of the pancreatic head may be suspected if pancreatic duct dilatation is also found. This article presents some unusual cholangiographic pitfalls that were identified, which initially distracted from the ultimate diagnosis.