Management of a benign common bile duct stricture in a private medical setting: from stepwise diagnostic work-up to treatment strategy selection

Abstract

Background. Benign biliary strictures often mimic malignant biliary tract lesions in terms of clinical presentation and imaging fi ndings; therefore, biliary decompression should be combined with concurrent exclusion of malignancy.

Objective. To demonstrate the endoscopic management of a benign distal common bile duct stricture in a private medical setting, with emphasis on diagnostic escalation and the choice between endoscopic and surgical strategies.

Materials and methods. We report a clinical case of a 67-year-old patient with obstructive jaundice and normal tumor markers who underwent a combination of noninvasive imaging (ultrasound, MRCP, CT) and multiple endoscopic interventions: ERCP with endoscopic sphincterotomy, brush cytology and fluoroscopy-guided biopsy, cholangioscopy with targeted biopsy, staged balloon dilation, and stepwise stenting using plastic stents and fully covered self-expanding metal stents (FCSEMS).

Results. Initial MRCP fi ndings were consistent with a soft stone or biliary sludge, whereas CT revealed bile duct wall thickening, raising suspicion of neoplasia and prompting diagnostic escalation with extended tissue sampling. Repeated cytological and histological examinations, including cholangioscopy, did not confi rm malignancy, allowing the stricture to be interpreted as benign. A staged endoscopic approach with sequential increases in the number of plastic stents followed by FCSEMS placement achieved effective biliary decompression and symptom regression. However, stricture recurrence occurred after stent removal. Given the patient’s signifi cant cardiovascular comorbidity, deferring hepaticojejunostomy was clinically justifi ed in accordance with the patient’s preference and under close dynamic follow-up. Following a subsequent recurrence of jaundice, the patient was referred for surgical intervention.

Conclusion. In benign CBD strictures, the key priorities are early biliary decompression, exclusion of malignancy, and staged endoscopic management, which in private practice may achieve outcomes comparable to surgical reconstruction. Th e combination of brush cytology, fluoroscopy-guided biopsy, and cholangioscopy increases diagnostic confi dence and may support a justifi ed delay or avoidance of major reconstructive surgery, while preserving hepaticojejunostomy as an option in case of recurrence or failure of endoscopic therapy