Progress in determining the nature of bile duct strictures.

Leading articleProgress in determining the nature of bile duct strictures It is surprising that in 1993 patients can still be treated with radical radiotherapy, chemotherapy, or surgery, including liver transplantation, without establishing a definitive diagnosis.This happens, however, in patients with obstruc- tive jaundice caused by a bile duct stricture where there is difficulty in obtaining a tissue diagnosis.The age and frailty of this patient group are often used as justifications for limiting investigations and employing palliative methods of treatment such as endoscopic balloon dilatation or stenting.Although this may sometimes be appropriate, the lack of a tissue diagnosis undoubtedly results in some patients being inappropriately treated for malignant disease when a benign stricture is present and vice versa.It also hampers any objective assessment of the value of treatment in these patients.The adage of 'a diagnosis is not required because it does not affect management' is now outdated when many treatment options are available.Malignant bile duct strictures are mainly the result of cancer of the ampulla of Vater, pancreas, or bile duct and account for about 75% of patients presenting with extra- hepatic bile duct obstruction.In the remainder strictures are caused by benign conditions such as gall stones, surgical trauma, chronic pancreatitis, or rarer disorders such as sclerosing cholangitis or Caroli's disease.'