Case 11.5
The patient has worsening pruritus and jaundice. He denies any fever, chills or abdominal pain. A repeat MRCP shows a dominant stricture in the right intrahepatic duct but no mass is seen. CA 19-9 is normal. His labs showed total bilirubin of 3.5 mg/dL and alkaline phosphatase of 500 U/L. The patient is scheduled to undergo an ERCP.
Which of the following statements about the endoscopic management of patients with PSC is correct?
There is no need for antibiotics before ERCP in patients with PSC
Patients with PSC should receive antibiotics for prophylaxis before ERCP because of increased risk of cholangitis.
ERCP should be performed routinely in patients with PSC even without any worsening labs or symptoms
- ERCP should be considered only if worsening symptoms including pruritus, jaundice, recurrent cholangitis or increasing bilirubin/cholestasis labs or progressive biliary dilatation on imaging studies.
Dominant strictures are rare in PSC
Dominant strictures, defined as stenosis of less than 1.5 mm in the common bile duct or less than 1 mm in the hepatic ducts, are seen in about 50% of patients with PSC. Dominant strictures are associated with poor outcomes in patients with PSC.
Dominant strictures are associated with poor outcomes in patients with PSC
Mean survival of those with dominant strictures was worse than that for those without dominant strictures. ERCP is indicated for dominant strictures. Cholangiocarcinoma needs to be ruled out in every patient with PSC developing a dominant stricture. A careful evaluation of dominant strictures with ERCP with brushing cytology and FISH (florescence in situ hybridization, if available) is recommended.