Digital Cholangioscopy with Narrow Band Imaging and Confocal Microscopy
Comments: Cholangioscopy for direct visualization of the biliary tract can be performed perorally, percutaneously or intraoperatively. Perorally we may use a semi-disposable fiber optic system, or reusable fiberoptic or digital system. Cholangioscopy diagnostically can characterize strictures, determine tumor extension and help in the detection of occult cancers in PSC. Therapeutic applications include management of difficult biliary stone, palliation of biliary malignancy and selective cannulation of the gallbladder or intrahepatic ducts. We performed digital Cholangioscopy using a modified duodenoscope with intraductal narrow band imaging capabilities. We also performed confocal microscopy n these cases.
The application of narrow band imaging in the biliary tract can identify exact cancerous extent and detect tumor vessals as seen on these slides. Application of Confocal microscopy in the biliary tract can differentiate normal versus abnormal epithelium, attempt to detect malignant transformation in PSC and possibly provide real-time cytology. You can see normal reticular pattern of the vessals on the left, but on the right malignant abnormal hyperchromatic, stubby, short vessals.
Case 1 is a 57 year old man with a history of liver transplantation now presenting with jaundice. Doppler ultrasound and CT scan showed hepatic artery thrombosis and a dilated biliary tract. On ERCP, we identified irregular ductal contour in the intrahepatics, intraductal longitudinal filling defects below that and a narrowing at the anastomosis. On performing cholangioscopy, we first passed the scope into the native bile duct and slowly approach the area of the narrowing. As we approach the anastomosis we can see a normal biliary epithelium and as we slowly traverse this narrowing we see a completely abnormal epithelium and as we slowly traverse this narrowing we see a completely abnormal epithelium in the transplanted bile duct. Indeed, in the transplanted bile duct we see sloughing if the biliary epithelium and the formation of the biliary epithelium associated with the hepatic artery thrombosis. We perform narrow band imaging in an attempt to further characterize our findings. On narrow band imaging the bile appears pink. As we withdraw under white light, we once again pass the area of stenosis and into the normal duct. Hence, on cholangioscopic diagnosis we have identified the anastomotic stricture and the ischemic necrosis and sloughing with formation of biliary casts.
Case 2 is a 74 year old woman presenting with painless jaundice with dilated ducts seen on CT scan. On ERCP we find a Bismuth 3 stricture at the hilum. On cholangioscopy at the lower portion of this hilar stricture we find an extrinsic compression from lymph nodes in that area. Hence the lower part of this hilar stricture is from lymph node obstruction. We then perform narrow band imaging which shows no characteristic tumor vessals and a fairly normal biliary epithelium. Once again the bile appears pink on the narrow band imaging. On performing confocal microscopy we see a fine reticular pattern associated with normal biliary epithelium. As we traverse this stricture and move towards the upper hilar stricture we see a completely different mucosa. We first notice a large amount of mucin within the duct and an irregular, strictured biliary epithelium. As we move further upward and switch to narrow band imaging, we start recognizing clearly papillary structures protruding into the bile duct causing the stenosis. These papillary structures are characteristic of papillary cholangiocarcinoma. In addition, on narrow band imaging, we are able to identity a large number of tumor vessals within these strictured areas. When we compare white light cholangioscopy with narrow band imaging of the same area we can clearly see the well visualized tumor vessals. On performing confocal microscopy we see hyperchromatic, stubby, short vessals which are fairly characteristic of malignancy in the biliary tree. Hence on cholangioscopic diagnosis the lower stricture is from nodal obstruction while the upper part of this stricture is from a cholangioracinoma which is then confirmed by cytology see on the right.
Case 3 is a 47 year old woman with primary sclerosing cholangitis now presenting with jaundice. The ERCP one year back showed characteristic PSC and the current ERCP shows a high degree of obstruction. On Cholangioscopy we can see the characteristic appearance of PSC with sclerosis and pitting of the bile duct. On narrow band imaging we are able to further characterize the epithelium which again shows sclerosis and pitting associated with normal biliary epithelium. Hence on cholangioscopic diagnosis this is probably a non-malignant PSC stricture as suggested by cytology.
Conclusion: Cholangiosopy has finally come of age with the digital cholangioscopy with intraductal narrow band imaging and confocal microscopy enhancing biliary imaging and diagnosis.
| Contributed by: |
Ram Chuttani, M.D. Chief of Endoscopy Beth Israel Deaconess Medical Center |
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Citation: Chuttani, R. (Jun 01 2009). Digital Cholangioscopy with Narrow Band Imaging and Confocal Microscopy. The DAVE Project. Retrieved Feb, 9, 2010, from http://daveproject.org/viewfilms.cfm?film_id=860 Times viewed since Feb 2006: 1964 |
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