Biochemical and radiological predictors of malignant biliary strictures.
OBJECTIVE
Differentiation of benign biliary strictures (BBS) from malignant biliary strictures (MBS) remains difficult despite improvement in imaging and endoscopic techniques. The aim of this study was to identify the clinical, biochemical and or radiological predictors of malignant biliary strictures.


METHODS
We retrospectively reviewed all charts of patients who had biliary strictures (BS) on endoscopic retrograde cholangiopancreatography (ERCP) or percutaneous cholangiography (PTC) in case of unsuccessful ERCP from March 1998 to August 2002. Patient characteristics, clinical features, biochemical, radiological and biopsy results were all recorded. Stricture etiology was determined based on cytology, biopsy or clinical follow-up. A receiver operator characteristic (ROC) curve was constructed to determine the optimal laboratory diagnostic criterion threshold in predicting MBS.


RESULTS
One hundred twenty six patients with biliary strictures were enrolled, of which 72 were malignant. The mean age for BBS was 53 years compared to 62.4 years for MBS (P=0.0006). Distal bile duct stricture was mainly due to a malignant process 48.6% vs 9% (P=0.001). Alkaline phosphates and AST levels were more significantly elevated in MBS (P=0.0002). ROC curve showed that a bilirubin level of 84 micromol/L or more was the most predictive of MBS with a sensitivity of 98.6%, specificity of 59.3% and a positive likelihood ratio of 2.42 (95% CI=0.649-0.810). Proximal biliary dilatation was more frequently encountered in MBS compared to BBS, 73.8% vs 39.5% (P=0.0001). Majority of BBS (87%) and MBS (78%) were managed endoscopically.


CONCLUSIONS
A serum bilirubin level of 84 micromol/L or greater is the best predictor of MBS. Older age, proximal biliary dilatation, higher levels of bilirubin, alkaline phosphatase, ALT and AST are all associated with MBS. ERCP is necessary to diagnose and treat benign and malignant biliary strictures.
Al-Mofleh
Ibrahim-A
IA
Gastroenterology Division, Department of Medicine (38), King Khalid University Hospital, PO Box 2925, Riyadh 11461, Kingdom of Saudi Arabia.
Aljebreen
Abdulrahman-M
AM
Al-Amri
Saleh-M
SM
Al-Rashed
Rashed-S
RS
Al-Faleh
Faleh-Z
FZ
Al-Freihi
Hussein-M
HM
Abdo
Ayman-A
AA
Isnani
Arthur-C
AC
D000367:Age Factors; D001660:Biliary Tract Diseases / Q000097:blood / Q000175:diagnosis / Q000000981:diagnostic imaging / Q000473:pathology; D001661:Biliary Tract Neoplasms / Q000097:blood / Q000175:diagnosis / Q000000981:diagnostic imaging / Q000473:pathology; D001663:Bilirubin / Q000097:blood; D002758:Cholangiography; D002760:Cholangiopancreatography, Endoscopic Retrograde; D003251:Constriction, Pathologic / Q000097:blood / Q000175:diagnosis / Q000000981:diagnostic imaging / Q000473:pathology; D006801:Humans; D008875:Middle Aged; D011237:Predictive Value of Tests; D012372:ROC Curve; D012189:Retrospective Studies; D012680:Sensitivity and Specificity
D001663:Bilirubin